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DUKE 

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LIBRARY 

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Dr.   A.    Cheatham 


THE 


MORBID  ANATOMY 


OF 


SOME  OF  THE  MOST  IMPORTANT  PARTS 


OF    THE 


HUMAN  BODY. 


BY 
MATTHEW  BAILLIE,  M.  D.  F.  R.  S. 

FELLOW  OF  ME  ROYAL  SOCIETIES  OF  LONDON  AND 
EDINBURGH,  AND  FELLOW  OF  THE  ROYAL  COL' 
LEGE  OF  PHYSICIANS  IN  LONDON. 


THE  SECOND  AMERICAN, 

PROM  THE  THIRD  LONDON  EDITIOX, 
CORRECTED. 


-v 


1VALP0LE :  N.  II. 


PRINTED   BY  G.  Vf.  NICHOLS,  FOR  W.  FESSENDEN,  BOOKSELLER, 
BRATTLEBOROUGH, VT. 

1803. 


TO 

DAVID  PITCAIRN,  M.  D. 

F.  It.   S.    6fc,  ^c. 

AS  A 

TESTIMONY  OF  HIGH  ESTEEM  FOR  HIS 
CHARACTER, 

AND   OF 
GRATITUDE  FOR  MANY  KIND  OFFICES, 

THIS    WORK 

IS    INSCRIBED, 
DY  MIS  FAITHFUL  FRIEND  AND  SERVANT, 

MATTHEW  BAILLIE. 


preface  to  the  fitgt  <£Dttton. 


SOME  diseases  consist  only  in  morbid  actions,  but  do  not  pro- 
duce any  change  in  the  structure  of  parts  ;  thtsc  do  not  ad- 
nut  of  anatomical  inquiry  after  death.  There  are  other  diseases, 
however,  where  alterations  in  the  structure  take  place,  and  these 
become  the  proper  subjects  of  anatomical  examination. 

The  object  of  this  work  is  to  explain,  more  minutely  than  has 
hitherto  been  done,  the  changes  of  structure  arising  from  morbid 
actions  in  some  of  the  most  important  parts  of  the  human  body. 

This,  I  hope,  will  be  attended  with  sopie  advantages  to  the 
general  science  of  medicine,  and  ultimately  to  its  practice.  It  is 
very  much  to  be  regretted'  that  the  knowledge  ol  morbid  struc- 
ture does  not  lead  with  certainty  to  the  knowledge  of  morbid  ac- 
tions) although  f  he  one  is  the  effect  of  the  other  ;  yet  surely  it 
lavs  the  most  solid  foundation  for  prosecuting  such  enquiries  uith 
Micocss.  In  proportion,  therefore,  as  we  shall  become  acquaint- 
ed with  the  changes  produced  iii  the  structure  of  parts  from  dis- 
easrd  actions,  we  shall  be  more  likely  to  make  some  progress  to- 
wards a  knowledge  of  the  actions  themselves,  although  it  must  he 
very  slowly.  The  subject  in  itself  is  extremely  difficult,  because 
morbid  actions  are  going  on  in  the  minute  parts  of  an  animal  body 
excluded  from  observation  ;  but  still  the  examination  of  morbid 
structure  is  one  of  the  most  probable  means  of  throwing  light  up- 
on it. 

A  second  advantage  arising  from  the  more  attentive  examina- 
tion of  morbid  structure  is,  that  we  shall  be  able  to  distinguish 
between  changes  which  may  have  some  considerable  resemblance 
to  each  other,  and  which  have  been  generally  confounded.  This 
will  ultimately  lead  to  a  more  attentive  observation  of  symptoms 
while  morbid  actions  are  taking  place,  and  be  the  means  of  dis- 
tinguishing diseases  with  greater  accuracy.  When  this  has  been 
done,  it  may,  perhaps,  produce  a  successful  enquiry  after  the 
most  proper  method  of  treatment. 

Another  advantage  arising  from  a  more  attentive  observation  of 
morbid  structure  is,  that  we  shall  be  better  fitted  to  detect  diseas- 
ed alterations  in  the  organization  of  parts  which  are  but  little,  or 
not  at  all  known.  This  will  lay  the  foundation  of  ourinquiry  ir-to 
the  diseases  themselves,  so  that  we  sluill  add  to  our  knowltdgc  of 
the  pathology  of  the  body,  and  perhaps  also  to  out  knowledge  of 
Feuudies. 


vi  PREFACE  TO  THE 

A  fourth  advantage  still  from  observing  attentively  morb».d 
structure  is,  that  theories  takenup  hastily  about  diseases  will  be 
occasionally  corrected.  The  human  mind  is  prone  to  form  opin- 
ions upon  every  subject  which  is  presented  to  it,  but  from  a  nat- 
ural indolence  is  frequently  averse  to  inquire  into  the  circumstan- 
ces which  can  alone  form  a  sufficient  ground  for  them.  This  is 
the  most  general  cause  of  faise  opinions,  which  have  not  only  per- 
vaded medicine,  but  almost  every  other  branch  of  knowledge. 
When,  however,  the  mind  shall  be  obliged  to  observe  facts  which 
cannot  be  reconciled  with  such  opinions,  it  will  be  evident  that 
ihe  opinions  are  ill  founded,  and  they  will  be  laid  aside.  We 
grant,  it  does  not  always  happen  that  men  are  induced  to  give  up 
their  opinions,  or  even  to  think  them  wrong,  upon  observing 
facts  which  do  not  agree  \with  them,  but  surely  it  is  the  best 
means  of  producing  this  effect  ;  and  whatever  change  may  be 
"wrought  on  the  individuals  themselves,  the  world  will  be  convin- 
ced,   who  have  fewer  prejudices  to  combat. 

A  person  who  previously  had  attended  very  accurately  to  symp- 
toms, but  was  unacquainted  with  the  disease,  when  he  comes  to 
examine  the  body  after  death,  and  finds  some  of  the  appearances 
that  are  described  in  tliis  Treatise,  will  acquire  a  knowledge  of  the 
whole  disease,  lie  will  be  able  to  guide  himself  on  such  knowl- 
edge in  similar  cases,  and  also  to  inform  others.  It  may,  per- 
haps, too,  lead  him  to  a  proper  method  of  treatment. 

When  a  person  has  become  well  acquainted  with  diseased  ap- 
pearances, he  will  be  better  able  to  make  his  remarks,  in  examin- 
ing dead  bodies,  so  as  to  judge  more  accurately  how  far  the  symp- 
toms and  the  appearances  agree  with  each  other. ;  he  will  be  able 
also  to  rjive  a  more  distinct  account  of  what  he  has  observed,  so 
that  his  data  will  become  a  more  accurate  ground  of  reasoning 
for  others. 

The  natural  structure  of  the  different  parts  of  the  human  body 
has  been  very  minutely  examined,  so  that  anatomy  may  be  said 
to  have  arrived  at  a  high  pitch  of  perfection  ;  but  our  knowledge 
©f  the  changes  of  structure  produced  by  disease,  which  maybe 
called  the  Morbid  Anatomy,  is  still  very  imperfect.  Such  chan- 
ges have  commonly  been  observed  only  in  their  more  obvious  ap- 
pearances, and  very  seldom  with  much  minuteness  or  accuracy 
of  discrimination. 

Any  works  explaining  morbid  structure  which   I   have  seen, 

are  very   different  in  their  plan  from  the  present  :  they  either 

consist  of  cases  containing  an  account  of  diseases  and   dissections 

collected  together  in  periodical  publications,  without  any  natural 

connexion  among  each  other  ;  or  consist  of  very  large  collections 

©f  cases,  arranged  according  to   some  order.     In  some  of  these 

periodica]  works, the  diseased  structure   has  been   frequently  ex- 

',v.i;i"d  with  a  sueffiient  degree  of  accuracy,  but  in    all  the  larger 

:>  has  been  often  described  too  generally.     The  descriptions 

e  prii  cipal   diseased  appearances,    have  been  sometimes 

by  taking  notice  of  smaller  collateral  circumstances, 


FIRST  EDITION'.  tii 

which  had  no  connection  with  them  or  the  diseases  from  whence 
they  arose.  Both  of  these  faults  too  frequently  occur,  even  in  the 
stupendous  work  of  Morgagni  de  Causis  et  Sedibus  Morborunv 
upon  which,  when  considered  in  all  its  parts,  it  would  be  difficult 
to  bestow  too  high  praise.  Besides,  the  bulk  of  these  very  large 
collections  prevents  them  from  being  generally  in  the  possession 
of  practitioners,  and  also>  renders  them  more  difficult  to  consult. 

In  the  present  work  we  propose  not  to  give  cases  ,•  but  simply 
an  account  of  the  morbid  changes  of  structure  which  take  place 
in  the  thoracic  and  abdominal  viscera,  in  the  organs  of  genera- 
tion in  both  sexes,  and  in  the  brain.  This  will  be  done  according 
to  a  local  arrangement,  very  much  in  the  same  manner  as  if 
we  were  describing  natural  structure,  and  will  be  accompanied 
with  observations  upon  morbid  actions  which  may  occasionally 
arise.  My  situation  has  given  me  more  than  the  ordinary  oppor- 
tunities of  examining  morbid  structure.  Dr.  Hunter's  collec- 
tion contains  a  very  large  number  of  preparations  exhibiting  mor- 
bid appearances]  which  I  can  have  recourse  to  at  any  time  for  ex- 
amination. Being  physician  to  a  large  hospital,  and  engaged  ii» 
teaching  anatomy,  I  have  also  very  frequent  opportunities  of  ex- 
amining diseases  in  dead  bodies.  This  work  will  therefore  chief- 
ly contain  an  account  of  the  morbid  appearances  which  I  have  seen 
myself  ;  but  I  shall  also  take  advantage  of  what  has  been  observ- 
ed by  others.  It  is  intended  to  comprehend  an  account  of  the 
most  common,  as  well  as  many  of  the  very  rare  appearancesof 
disease  in  the  vital  arid  more  important  parts  of  the  human  body, 
from  the  nature  of  this  undertaking  it  is  evident)  that  it  must  be 
progressive  :  some  appearances  of  disease  will  be  observed  in 
future,  with  which  we  are  at  present  totally  unacquainted]  and 
others  which  we  know  very  little  of  now,  will  afterwards  be  known 
perfectly. 

Although  I  have  ventured  to  lay  this  work  before  the  Public, 
yet  I  am  very  sensible  of  its  imperfections.  Some  appearand  -» 
are  described  which  I  have  only  had  an  opportunity  of  seeing 
once,  and  which,  therefore,  may  be  supposed  to  be  described  lc^s 
fully  and  exactly  than  if  I  had  been  able  to  make  repealed  exam- 
inations. There  are  others  which  I  have  seen  long  before  I  had 
formed  any  idea  ofthis  undertaking,  and  which  I  may  be  suppo- 
sed to  have  observed  less  accurately  than  if  I  had  had  a  particu- 
lar object  in  view.  There  are  others  still,  which  I  only  have  had  an 
opportunity  of  examining  in  preparations.  In  some  of  these, 
certain  appearances  may  be  supposed  to  be  lost,  which  might 
have  been  observed  had  they  been  examined  recently  after  death. 
All  of  these  are  sources  of  inaccuracy,  which  maybe  said  in  some 
degree  to  be  unavoidable.  I  have  endeavoured,  however,  to  be 
accurate;  and  if  the  Public  should  approve  of  my  plan,  I  shall 
be  very  careful,  by  the  addition  of  new  materials,  and  by  repeated 
observations,  to  render  this  publication  more  perfect. 


preface  to  the  ^econo  Coition, 


A  SECOND  Edition  of  this  Treatise  is  now  offered  to  the 
Public.  It  is  considerably  enlarged,  and  I  hope  more  cor- 
rect than  the  former.  The  additions  are  principally  derived  from. 
What  1  have  remarked  myself;  but  they  are  also  taken  from  the 
observations  of  others,  and  more  especially  from  those  of  Dr. 
Soemmering,  Professor  of  Medicine  in  the  University  of  May- 
ence,  one  of  the  most  distinguished  anatomists  in  Germany.  He 
was  pleased  to  think  so  favourably  of  my  attempt  to  improve  the 
knowledge  of  diseased  appearances  in  the  human  body,  as  to 
translate  the  first  Edition  of  the  Morbid  Anatomy  into  the  Ger- 
man language,  and  to  add  to  it  many  new  Cases,  and  copious 
Notes.  It  has  given  me  the  most  sincere  satisfaction,  to  find  that 
our  observations  and  opinions  coincide  so  much  with  those  of  each 
other.  Had  the  plan  of  my  work  been  different,  I  might  have 
derived  much  more  assistance  from  the  valuable  labours  of  Pro- 
fessor Soemmering,  but  many  of  the  additions  which  he  has 
made  do  not  strictly  fall  within  it. 

To  the  Morbid  Appearances  I  have  attempted  to  subjoin  the 
Symptoms  connected  with  them.  This  part  of  the  undertaking 
is  attended  with  many  difficulties,  and  I  feel,  very  sensibly,  how 
much  the  execution  of  it  stands  in  need  of  the  kind  indulgence 
of  the  public.  If  this  work  shall  ever  come  to  another  Edition,  I 
hope  to  be  able  to  render  the  account  of  symptoms  less  imperfect. 

The  difficulties  which  attend  an  attempt  to  ascertain  the  symp- 
toms of  diseases,  are  derived  from  various  sources.  The  same 
symptoms  are  not  uniformly  connected  with  the  same  changes  of 
morbid  structure  in  the  body.  In  many  cases  too  the  symptoms 
are  nearly  the  same,  where  the  morbid  changes  of  structure  are 
very  different.  This  is  particularly  exemplified  in  diseases  of  the 
brain,  and  of  the  heart.  Patients  often  explain  very  imperfectly 
their  feelings,  partly  from  the  natural  deficiency  of  language,  and 
partly  from  being  misled  by  preconceived  opinions  about  the  na- 
ture of  their  complaints.  Medical  men  also,  in  examining  into 
the  symptoms  of  diseases,  sometimes  put  their  questions  inaccu- 
rately, and  not  unfrequently  mislead  patients  into  a  false  descrip- 
tion, from  some  opinion  about  the  disease  which  they  have  too 
hastily  adopted.  All  of  these  are  formidable  difficulties, 
which  obstruct  the  progress  of  our  knowledge  of  the  symp- 
toms cf  disease*  ;    but   the   accumulated  observations   of  ma» 

B 


■x  PREFACE,  kc. 

ny  individuals  will  probably,  at  length,  in  a  great  measure  over- 
come them. 

In  describing  the  symptoms  of  diseases,  I  have  not  entered  in- 
to a  minute  detail.  This  belongs  properly  to  the  plan  of  a  writer, 
who  proposes  to  take  a  full  view  of  any  particular  disease.  I  have 
mentioned  those  symptoms  only  which  are  most  constant,  and 
most  strongly  characteristic  of  the  diseases  to  which  they  belong. 
Many  diseased  appearances  are  described  in  this  work,  to  which 
there  are  added  no  corresponding  symptoms  ;  and  this  depends 
upon  different  causes.  The  first  is,  that  there  are  many  morbid 
changes  of  structure  in  the  body,  the  corresponding  symptoms 
of  which  are  not  ascertained.  The  second  is,  that  many  morbid 
changes  of  structure  are  produced  by  causes  which  disturb  the 
constitution  so  little,  as  to  be  attended  with  symptoms  too  slight- 
ly marked  for  observation.  The  third  and  last  is,  that  the  symp- 
toms belonging  to  some  diseased  appearances,  fall  so  immediately 
under  the  cognizance  of  the  eye,  or  of  the  touch,  as  to  be  included 
in  a  description  of  the  diseased  appearances  themselves,  and  to 
render  any  further  account  of  them  supeifluous. 

The  account  of  symptoms  is  placed  at  the  end  of  each  chapter, 
after  the  description  of  the  diseased  appearances,  that  the  anatom- 
ical part  of  the  work  may  not  be  interrupted.  In  a  very  few  in- 
stances, however,  the  account  of  the  symptoms  has  not  been  sep- 
arated from  the  anatomical  description  of  the  morbid  appearances, 
viJF.  where  so  little  of  the  symptoms  was  known  as  not  to  admit 
of  a  distinct  account  being  given  of  them. 

Besides  an  account  of  morbid  appearances,  a  few  cases  of  mal- 
formation are  blended  in  this  work.  They  do  not  strictly  fall 
within  its  plan  ;  I  have,  therefore,  added  only  a  few,  which  are 
important,  and  which  have  almost  all  occurred  to  my  own  obser- 
vation. 


LONDON, 

JVot.  20,  *7Q7. 


ADVERTISEMENT 


TO    THE 

THIRD     EDITION. 


J.  OR  the  last  seven  years  I  have  been  so  much  engaged 
in  the  practical  duties  of  my  Profession,  as  only  to  have  had 
occasional  opportunities  of  inspecting  dead  bodies.  I  have 
therefore,  scarcely  been  able  to  make  any  additions  to  this 
Work,  but  I  have  made  such  corrections  of  it,  as  moro 
rcilection  and  experience  have  suggested  to  me,  and  I  hope 
it  will  be  found  to  be  considerably  improved. 

The  Second  Edition  of  this  treatise  was  translated  about 
three  years  ago,  by  Dr.  Ferrall,  into  the  French  language. 
The  translation  is  made  with  great  fidelity  ;  but,  as  it  is 
neither  accompanied  with  Notes,  nor  with  the  addition  of 
any  new  cases,  I  have  not  been  able  to  derive  any  advantage 
from  it,  in  preparing  this  Third  Edition  for  the  Press. 

LONDON, 

Feb.    1,    1807. 


.Stem -^ mi  ■  t#d 


MORBID  ANATOMY,  &c, 


CHAPTER    I. 

DISEASED   APFEARANCES    OF   THE    PERICARDIUM. 

Inflammation  of  the  Pericardium. 

THE  pericardium,  or  the  membrane  which  sur- 
rounds the  heart  like  a  bag,  and  is  reflected  up- 
on its  surface,  giving  it  a  smooth  external  covering, 
is  liable  to  inflammation.  This  is  not  a  very  com- 
mon disease,  although  it  happens  sufficiently  often  to 
afford  frequent  opportunities  of  examining  its  effects 
after  death.  The  disease,  from  its  nature,  cannot  be 
.confined  to  any  particular  periods  of  life  ;  yet  from 
what  I  have  seen,  I  should  believe  that  it  takes  place 
more  cemmonly  when  the  body  has  been  for  some 
time  in  its  adult  state,  than  either  in  childhood  or  ad- 
vanced age. 

In  inflammation  of  the  pericardium,  the  membrane 
is  frequently  thicker  than  in  its  natural  state,  and  is 
also  a  little  more  pulpy.  This  change  depends  upon 
additional  matter  being  thrown  into  the  membrane  by 
the  increased  action  of  the  small  vessels  which  are  dis- 
tributed upon  it.  It  is  also  crowded  with  a  very  un- 
usual number  of  minute  vessels,  which  contain  florid 
blood.  Upon  the  inside  of  the  pericardium  there  is 
a  layer  of  a  yellowish  pulpy  matter,  which  commonly 
docs  not  adhere  firmly  to  it,  but  may  be  easily  scpa- 


[  1*  ] 

rated.  It  generally  extends  over  the  whole  of  its  in- 
ner surface,  and  varies  a  good  deal  in  its  thickness.  — 
In  some  instances  it  is  as  thin  as  a  wafer,  and  in  others 
as  thick  as  a  half-crown.  In  this  matter,  which  is 
lining  the  pericardium,  there  is  frequently  to  be  seen 
a  slight  red  ^»pearance,  from  small  blood  vessels 
whieh  are  ramifying  through  it ;  but  these  are  most 
distinctly  detected  by  filling  them  with  the  fine  injec- 
tion. They  are  sometimes  numerous,  and  may  be 
clearly  traced  passing  from  the  pericardium  into  the 
pulpy  matter ;  in  which  I  have  also  seen  small  spots 
of  florid  blood.  These  newly  formed  vessels  afford 
a  very  convincing  proof  of  this  extravasated  matter 
possessing  a  living  principle  ;  for  one  cannot  imagine 
that  blood  vessels  would  shoot  into,  and  form  a  num- 
ber of  new  branches  in  a  substance  which  is  dead.* 
Upon  its  inner  surface,  this  matter  very  frequently 
throws  out  little  irregular  processes,  giving  the  ap- 
pearance of  lace- work,  and  junctions  are  often  formed 
between  that  portion  of  it  lining  the  pericardium, 
which  is  reflected  like  a  bag,  and  that  other  portion 
lying  upon  the  pericardium,  which  is  the  immediate 
covering  of  the  heart.  This  matter  has  a  very 
close  resemblance,  both  in  colour  and  structure,  to 
the  coagulable  lymph  of  the  blood,  and  is  probably 
nothing  else  than  this  substance  separated  from  the 
blood  by  a  particular  action  of  the  small  vessels  of 
the  pericardium. 

At  the  same  time  that  this  layer  of  pulpy  matter  is 
thrown  out  upon  the  inner  surface  of  the  pericardium, 
there  is  accumulated  in  its  cavity  more  or  less  of  a 
brownish  or  yellowish  fluid.  There  is  sometimes  only 
a  few  ounces  of  it ;  at  other  times  more  than  a  pint. 
In  it  are  floating,  loose  shreds  of  the  pulpy  matter  for- 
merly described,  and  there  is  also  occasionally  some 
mixture  of  pus.     This  fluid  resembles  in  its  proper- 


*  This  is  an  argument  used  by  Mr.  Hunter,  in  support  of  the  living  princi- 
ple of  the  blood. 


C     15     ] 

ties  the  scrum  of  the  blood,  and  has  commonly  been 
considered  as  the  scrum. 

Inflammation  of  the  pericardium  sometimes  advan- 
ces to  form  pus,  although  rarely.  Of  this  I  have  seen 
one  instance.  The  pericardium  was  much  thickened, 
was  inflamed,  and  lined  with  coagulable  lymph  ;  but 
there  was  no  sign  of  ulceration  in  any  part  of  it.  This 
last  circumstance  will  be  more  particularly  taken  no- 
tice of,  when  we  come  to  speak  of  the  diseased  ap- 
pearances of  the  pleura.  The  pericardium  in  this 
case,  contained  more  than  a  quart  of  common  pus. 
When  that  part  of  the  pericardium  is  inflamed  which 
forms  the  immediate  covering  of  the  heart,  the 
muscular  substance  of  the  latter  is  occasionally  in- 
flamed to  some  depth. 

When  the  pericardium,  or  any  other  membrane 
lining  a  circumscribed  cavity,  is  inflamed,  and  a  layer 
of  coagulable  lymph  is  formed  upon  its  surface,  there 
is  a  peculiar  disposition  given  to  the  coagulable  lymph 
by  the  action  of  the  small  vessels  which  pour  it  out. 
This  peculiar  disposition  is  its  tendency  to  immediate 
coagulation.  As  soon  as  the  coagulable  lymph  is 
thrown  out  upon  an  inflamed  surface,  one  must  sup- 
pose that  it  immediately  coagulates.  If  it  did  not  im- 
mediately coagulate,  but  remained  for  some  time  fluid, 
as  in  the  spontaneous  separation  of  the  constituent 
parts  of  the  blood  in  a  bason  after  common  bleeding, 
then  the  coagulable  lymph  would  form  a  small  cake 
at  the  bottom  of  the  serum,  easily  moveable  from  one 
part  ©f  the  cavity  to  another,  and  would  not  form  a 
layer  adhering  to  the  surface  of  the  inflamed  mem-, 
brane. 

The  serum  is  generally  in  a  much  larger  quanti- 
ty than  could  take  place  in  consequence  of  its  mere 
spontaneous  separation  from  the  coagulable  lymph 
which  is  spread  upon  the  surface  of  the  inflamed  mem- 
brane. The  blood  vessels,  therefore,  which  arc  dis- 
tributed in  the  layer  of  the  coagulable  lymph,  would 
seem  to  pour  out  some  quantity  of  serum.  While 
the  inflammation  is  receding,  and  the  coagulable  lymph 


[     18     ] 

is  changing  into  adhesions,  the  serum  is  generally  ta- 
ken up  from  the  cavity  ;  and  this  effect  must  be  sup- 
posed to  be  produced  by  the  action  of  absorbent  ves- 
sels. The  membrane  of  adhesions  must  therefore 
have  absorbent  vessels  belonging  to  it,  which  have 
probably  been,  formed  by  the  elongaticv.  or  growth  of 
the  absorbents  of  the  inflamed  membrane,  shooting 
into  the  coagulable  lymph. 

Besides  serum,  we  have  mentioned  that  pus  is 
sometimes  found  in  an  inflamed  circumscribed  cavity. 
When  this  is  the  case,  it  seems  extremely  probable 
that  the  small  arteries,  distributed  in  the  layer  of  the 
coagulable  lymph,  have  poured  out  the  pus.  This,  I 
believe,  has  not  hitherto  been  thought  of;  but  it  is 
difficult  to  conceive  under  these  circumstances  any 
other  source  from  whence  the  pus  is  derived.  If  the 
pus  be  supposed  to  be  formed  by  the  arteries  which 
ramify  in  the  inflamed  membrane  itself,  then  it  must 
transude  through  a  layer  of  coagulable  lymph,  which 
often  is  of  considerable  thickness,  before  it  accumu- 
lates in  the  cavity.  This,  however,  is  not  likely  ;  and 
as  arteries  pass  from  the  original  membrane  into  the 
layer  of  the  coagulable  lymph,  it  becomes  more  rea- 
sonable to  suppose  that  pus  is  formed  by  the  arteries 
distributed  in  the  coagulable  lymph,  than  in  the  ori- 
ginal membr  ~e  itself. 


Adhesions  of  the  Pericardium  to  the  Heart. 

In  opening  dead  bodies,  adhesions  of  the  pericar- 
dium to  the  heart,  are  not  uncommonly  found.  The 
adhesion  is  sometimes  at  different  spots  ;  at  other 
times  is  extended  over  the  whole  surface.  It  either 
consists  of  a  thin  membrane,  or  of  a  more  solid  mat- 
ter. When  it  is  a  thin  membrane,  it  resembles  ex- 
actly the  common  cellular  membrane  of  the  body  ; 
and  when  the  matter  is  solid,  it  differs  only  a  little 
from  the  coagulable  lymph  of  the  blood,  recently 
thrown  out  upon  an  inflamed  surface.     Whether  the 


[     17     ] 

adhesion  be  in  the  one  way  or  the  other,  the  matter 
of  the  adhesion  is  in  both  cases  capable  of  being  ren- 
dered vascular  by  injection.  The  adhesion  too  is  in 
both  cases  formed  from  the  pulpy  matter  formerly 
explained,  for  I  have  oftener  than  once  had  an  oppor- 
tunity of  tracing  its  gradual  changes  into  each.  Such 
adhesions  are  to  be  considered  as  the  consequence  of 
inflammation,  and  shew  that  an  inflammation  of  the 
pericardium  may  be  survived.  They  connect  the 
pericardium  in  different  cases,  more  closely  or  loosely 
to  the  surface  of  the  heart  ;  and  where  the  connection 
is  close,  the  inflammation  has  probably  been  more 
recent ;  where  it  is  loose,  the  inflammation  has  prob- 
ably been  of  older  date,  so  that  time  has  been  given 
for  the  adhesions  to  be  elongated  by  the  motion  of 
the  heart. 

Dropsy  of  the  Pericardium. 

This  disease  is  not  uncommon,  and  I  believe  is 
most  frequent  at  an  advanced  period  of  life.  I  have 
seen  it,  however,  in  persons  considerably  under  the 
age  of  thirty  :  and  it  probably  also  happens  occasion- 
ally in  childhood,  I  have  seen  oftener  than  once  both 
anasarca  and  ascites  in  children  under  twelve  years 
old,  which  is  as  improbable  as  the  accumulation  of 
water  in  the  pericardium.  Water  is  sometimes 
found  accumulated  in  the  pericardium,  while  there  is 
none  in  any  other  cavity  ;  but  generally  it  is  accom- 
panied with  the  accumulation  of  water  in  the  other 
cavities  of  the  thorax. 

This  water  varies  a  good  deal  in  quantity,  amount- 
ing in  some  cases  hardly  to  two  ounces,  and  in  oth- 
ers to  more  than  a  pint.  Although  the  quantity  be 
Luge  which  may  happen  to  be  accumulated,  yet  the 
pericardium  is  never  very  much  stretched  ;  but  it 
always  appears  as  if  it  could  contain  a  greater  quanti- 
ty. It  is  probable,  therefore,  that  the  pericardium 
may  really  grow  so  as  to  keep  pace  with  the  accumu- 
lation ;  and  this  would  seem  to  be  necessarv,  in  order 

C 


[     18     ] 

that  the  heart  may  have  room  for  dilating  its  several 
cavities. 

The  fluid,  which  is  accumulated,  is  of  a  brown 
colour,  having  a  darker  or  lighter  shade  in  different 
cases,  and  resembles  in  its  properties  the  serum  of  the 
blood.  If  the  person  should  happen  at  the  same  time 
to  have  jaundice,  then  the  fluid  has  a  yellow  tinge 
from  the  bile.  It  has,  however,  freqnently  a  yellow- 
ish colour,  like  the  serum,  without  there  being  any 
reason  to  suppose  that  bile  has  been  circulating  with 
the  blood. 


Scrofulous  Tumours  in  the  Pericardium. 

I  had  once  an  opportunity  of  seeing  two  or  three 
scrofulous  tumours,  growing  within  the  cavity  of  the 
pericardium,  one  of  which  was  nearly  as  large  as  a 
walnut.  They  consisted  of  a  white,  soft  matter, 
somewhat  resembling  curd  or  new  cheese.  The  pe- 
ricardium is  a  very  unusual  part  of  the  body  to  be  at- 
tacked by  scrofula,  and  therefore  this  must  be  con- 
sidered as  a  very  rare  appearance  of  disease. 


The  Pericardium  almost  drif. 

I  have  twice  found  (and  it  has  been  seen  much  of- 
tener  by  an  anatomist,*  whose  authority  is  of  great 
weight)  the  pericardium  so  changed  as  to  resemble  a 
common  ox's  bladder  in  some  degree  dried  ;  or  like 
a  common  pericardium  which  had  been  for  some  time 
exposed  to  the  air.  As  the  thorax  and  abdomen 
were  enlire  in  both  cases,  no  opening  whatever  hav- 
ing been  made  into  either,  this  effect  could  not  arise 
from  evaporation.  Were  this  capable  of  taking  place, 
the  appearance  here  noticed,  would  be  very  usual  in 
examining  dead  bodies,  and  the  internal  parts  gencr- 

•  Mr.  Hunter- 


[      19     ] 

ally  would  be  affected  by  the  influence  of  the  same 
cause.  It  must  be  considered  therefore  as  the  effect 
of  a  process  which  was  going  on  during  life.  The 
cause  of  this  appearance  is  cither  a  defect  in  the  ac- 
tion of  the  exhalant  vessels  of  the  pericardium,  so 
that  the  fluid  which  naturally  lubricates  this  part,  is 
not  secreted  in  the  proper  quantity  :  or  it  is  an  in- 
creased action  of  the  absorbent  vessels  of  the  peri- 
cardium, by  which  the  lubricating  fluid  is  taken  up 
in  larger  proportion  than  it  is  deposited  by  the  exha- 
lant arteries. 


The  Pericardium  cartilaginous,  and  bony. 

A  portion  of  the  pericardium  has  in  some  instan- 
ces been  observed  to  be  converted  into  cartilage,* 
and  in  others  into  bonc,f  but  both  of  these  changes 
are  very  uncommon. 

I  had  an  opportunity  lately  of  examining  an  instance 
of  the  latter  sort,  in  which  the  ossific  process  had 
spread  over  a  considerable  portion  of  the  pericardium. 
A  cartilaginous  state  of  the  pericardium  has  not 
fallen  under  mv  own  observation. 


The  Pericardium  wanting. 

A  few  instances  have  occurred,  in  which  the  peri- 
cardium has  been  wanting,  from  a  delect  in  the  ori- 
ginal formation.  When  this  deficiency  takes  place, 
the  heart  appears  perfectly  bare  and  distinct  to  the 
eye,  upon  removing  the  sternum  and  the  cartilagin- 
ous extremities  of  the  ribs.  The  external  surface  of 
the  different  cavities  and  bloodvessels  of  the  heart  is 
been  as  distinctly  as  when  the  pericardium  is  laid  6p- 

•  S«e^Morgagni  de Cansis et  Sedlbus MorborurDj  E;;'st    Y,'/Al.  Ait.  10. 
j-  SceBonetus,  Tom.  I.  p    583. 


C   20   3 

en  in  the  natural  structure  of  these  parts.  A  close 
and  uniform  adhesion  of  the  pericardium  to  the  heart 
has  sometimes  been  mistaken  for  this  malformation, 
but  they  are  very  different  from  each  other.  When 
there  is  a  close  adhesion  of  the  pericardium  to  the 
heart,  the  external  surface  of  the  different  cavities 
and  blood  vessels  of  this  organ  does  not  come  into 
view,  upon  removing  the  sternum  and  a  part  of  the 
ribs.  The  whole  of  this  appearance  is  as  completely 
hid  as  in  the  healthy  structure.  It  is  only  when  the 
adhesion  is  removed  by  dissection  that  the  external 
surface  of  the  heart  and  its  blood  vessels  comes  into 
view.  When  there  is  an  adhesion  of  the  pericardium 
to  the  heart,  this  membrane  adheres  at  the  same  time 
closely  to  the  tendinous  part  of  the  diaphragm ;  but 
when  there  is  an  original  want  of  the  pericardium, 
the  heart  lies  loose  in  the  cavity  of  the  chest,  having 
no  connection  whatever  with  the  diaphragm,  and  is 
covered  by  the  pleura,  like  the  lungs.  I  have  had  an 
opportunity  of  seeing  once  an  example  of  a  want  of 
the  pericardium,  and  have  described  it  in  the  Medical 
and  Chirurgical  Transactions  f 


SYMPTOMS. 

The  symptoms  attending  inflammation  of  the  peri, 
cardium,  cannot  be  distinguished  in  practice  from  inv 
flammation  of  the  substance  of  the  heart.  Whenever 
the  inflammation  of  the  pericardium  is  violent,  the 
muscular  substance  of  the  heart  is  inflamed  to  some 
depth,  and  therefore  the  inflammations  of  both  parts 
are  often  blended  together.  The  symptoms,  which 
have  been  observed,  are  the  general  affection  of  the 
system  known  by  the  name  of  Symptomatic  Fever ; 
pain  in  the  region  of  the  heart,  which  is  often,  but  not 
always  attended  with  palpitations,  and  with  an  irregu.- 

t  See  Page  91,  VoJ.  I- 


I     21     ] 

lar  pulse  ;  cough  ;  difficulty  of  breathing  ;  and  som«. 
times  syncope. 


The  symptoms  attending  adhesions  of  the  pericar* 
dium  to  the  heart,  are  not  so  clearly  marked  as  to  be 
well  distinguished  in  practice.  When  the  adhesions 
are  partial  and  long,  so  that  the  heart  can  enjoy  a  free 
play  within  the  pericardium,  probably  little  or  no  in- 
convenience is  felt.  But  when  the  adhesions  are  close, 
and  extend  generally  over  the  surface  of  the  heart,  the 
following  symptoms  have  been  observed,  viz.  a  sense 
of  oppression,  and  sometimes  of  pain  in  the  situation 
of  the  heart ;  a  pulse  often  irregular  and  intermittent ; 
difficulty  of  breathing,  and  sometimes  a  dry  cough. 


When  water  is  accumulated  in  the  pericardium, 
the  symptoms  are  found  to  resemble  very  much  those 
belonging  to  hydrothorax,  and  have  not  been  clearly 
distinguished  from  them  by  authors.  These  symp- 
toms will  b«  afterwards  mentioned  when  we  come  to 
hydrothorax.  It  may  perhaps  serve  as  some  imper- 
fect ground  of  distinction  between  the  two  diseases, 
that  the  feeling  of  oppression  is  more  accurately  con- 
fined to  the  situation  of  the  heart,  and  the  heart  is 
more  disturbed  in  its  functions,  in  dropsy  of  the  peri- 
cardium, than  in  hydrothorax.  It  ought  at  the  same 
time  to  be  remarked,  that  the  two  diseases  are  often 
blended,  in  which  case,  these  grounds  of  distinction 
cannot  be  applied. 


The  case  of  scrofulous  tumours  growing  upon  the 
inside  of  the  pericardium,  which  I  have  described, 
was  combined  with  tubercles  of  the  lungs ;  and  the 
person  died  with  the  common  symptoms  of  pulmona- 
ry consumption.  Nothing  occurred  which  led  to  any 
suspicion  of  a  disease  in  the  pericardium.     It  seems 


C     22     ] 

to  me  reasonable  to  suppose,  that  when  scrofulous  tu- 
mours grow  in  the  pericardium,  there  will  hardly  be 
any  inconvenience  felt  while  they  are  small ;  but  when 
they  enlarge  very  much  in  size,  they  will  necessarily 
prevent  the  full  dilation  of  the  heart,  and  disturb  its 
functions.  This,  however,  will  probably  be  very  diffi- 
cult to  be  distinguished  from  the  disturbance  produ- 
ced by  other  causes,  which  must  in  the  same  manner 
impede  the  free  action  of  the  heart ;  as,  for  instance, 
the  accumulation  of  water  in  the  pericardium. 


The  symptoms  produced  by  a  defect  of  the  lubri- 
eating  fluid  in  the  pericardium,  arc  at  present  un- 
known. 


[     23     } 
CHAP.     II. 

DISEASED   APPEARANCES   OF   THE   HEART. 

Inflammation  of  the  Heart. 

INFLAMMATION  of  the  substance  of  the  heart 
is  a  rare  disease,  and  is  most  commonly  connected 
with  an  inflammation  of  the  pericardium.  When  the 
pericardium  covering  its  surface  is  inflamed,  the  in- 
flammation sometimes  passes  a  little  way  into  the  sub- 
stance of  the  heart.  That  part  of  it  becomes  much 
more  crowded  with  small  vessels  than  in  its  natural 
state,  and  there  are  sometimes  to  be  seen  in  it  a  few 
spots  of  extravasated  blood.  The  substance  of  the 
heart  may,  however,  be  inflamed,  without  inflamma- 
tion of  the  pericardium.  I  recollect  an  instance  of 
this  sort,  where  no  marks  of  inflammation  could  be 
observed  in  that  membrane,  but  where  there  was  a 
little  more  water  than  usual  in  its  cavity. 

Authors  have  mentioned  cases  of  abscesses  and  ul- 
cers* of  the  heart,  but  these  I  am  persuaded  are  ex- 
ly  rare.  It  happens  still  more  rarely  that  the  heart 
becomes  mortified,  although  this  diseased  state  of  it 
has  alsobcecn  observed.! 

JVJiite  Spot  upon  tire  Surface  of  the  Heart. 

In  opening  dead  bodies  there  is  very  often  to  te 
seen  upon  the  surface  of  the  heart,  a  white  opaqi  e 
spot  like  a  thickening  of  the  pericardium.  This  is 
sometimes  not  broader  than  a  six-pence  ;  at  other 
times  as  broad  as  a  crown-piece.  It  is  most  common- 
ly on  the  surface  of  the  right  ventricle,  and  is  rarely 


*  Vide  Morgagni,  Epist.  XXV.  Artie.  17.     Vide  B wet.  Tarn.  L  p.  849; 
and  also  Lieiuaud.  Tom.  II.  p.  27. 

t  Vide  Licutaud,  Tom.  II.  p.  33. 


[     24     ] 

fo  be  seen  either  on  the  surface  of  the  left  ventricle, 
or  of  the  auricles,  although  it  is  occasionally  on  both. 
It  consists  of  an  adventitious  membrane,  forme^d  on 
a  portion  of  the  pericardium  which  covers  the  heart, 
and  may  easily  be  dissected  off,  so  as  to  leave  the  pe- 
ricardium entire.  It  is  an  appearance,  I  believe,  of 
no  consequence  whatever,  and  is  so  very  common, 
that  it  can  hardly  be  considered  as  a  disease. 

Polypus. 

This  has  been  considered  by  the  older  anatomists, 
as  a  very  common  and  a  very  fatal  disease.  By  ma- 
ny of  the  moderns  it  has  been  rejected  as  a  disease 
altogether.  It  consists  of  a  mass  of  the  coagulable 
lymph,  which  fills  up  some  of  the  large  cavities  of  the 
heart,  particularly  the  ventricles,  and  extends  into  the 
neighbouring  large  vessels. 

The  coagulable  lymph  is  of  a  yellowish  white  co- 
lour, sometimes  of  a  very  yellow  colour,  and  has  con- 
siderable firmness.  It  fills  up  the  cavity  completely, 
or  nearly  so,  in  which  it  is  found ;  and  in  the  ventri- 
cles it  shoots  out  processes  among  the  fasciculi  of  the 
muscular  fibres.  From  this  circumstance  probably, 
it  has  derived  its  name.  It  also  extends  into  the  larger 
arteries  which  arise  from  the  ventricles,  and  is  often 
moulded  to  the  semi-lunar  valves  at  their  origin. — 
The  examples  of  this  appearance  which  it  has  occur- 
red to  me  to  observe,  have  been  chiefly  in  preparations, 
and  had  undoubtedly  taken  place  after  death.  In  or- 
der that  the  circulation  may  be  carried  on,  it  is  ne- 
cessary that  the  cavities  of  the  heart  be  free  for  the 
transmission  of  blood;  and  if  any  one  of  its  cavities 
should  be  plugged  up,  the  circulation  would  necessa- 
rily be  stopped  altogether.  A  polypus,  however, 
plugs  up  the  cavity  of  the  heart  in  which  it  is  formed 
so  entirely,  as  to  prevent  the  circulation.  It  may  be 
said,  perhaps,  that  polypi  are  formed  gradually,  and 
that  the  circulation  is  carried  on  fcr  some  time,  al- 
though very  imperfectly.  We  have  no  evidence,  how- 


C     25     ] 

ever,  ofcoagula  of  blood  being  formed  in  the  ordina- 
ry circulation,  where  there  is  a  healthy  structure  of 
the  parts  concerned  in  this  function.  When  polypi 
are  examined,  there  is  the  same  sort  of  appearance 
throughout  their  whole  substance  ;  which  shews  that 
the  whole  coagulum  had  been  formed  at  the  same 
time.  Both  of  those  circumstances  seem  to  contra- 
dict ven  strongly  the  opinion,  that  polypi  are  formed 
during  life.  When  polypi  are  formed,  I  believe  that 
the  coagulation  of  the  blood  does  not  take  place  very 
quickly  after  death.  They  are  without  any  admix- 
ture of  the  red  globules  of  blood,  and  therefore  the 
blood  has  been  sufficiently  long  in  coagulating  to  al- 
low the  globules  to  separate  from  the  other  parts,  in 
consequence  of  their  greater  specific  gravity. 

The  ordinary  coagulations  of  the  blood,  which  com- 
monly do  not  fill  up  very  fully  the  cavities  of  the  heart 
(although  instances  occasionally  occur  of  this  sort) 
take  place  pretty  soon  after  death,  because  the  red 
particles  of  the  blood  are  generally  arrested  in  the  co- 
agulum. It  may  be  worth  while  to  remark,  that  thert- 
is  sometimes  found  a  portion  of  a  coagulum  in  one  of 
the  ventricles  of  a  yellow  colour,  and  with  an  oily  ap- 
pearance, so  as  to  resemble  exactly  fat.  There  is, 
however,  no  admixture  of  oil  in  it,  and  it  possesses 
all  the  ordinary  properties  of  the  coagulable  lymph. 
The  yellow  colour  of  a  coagulum  sometimes  depends 
on  a  portion  of  the  bile  having  circulated  with  the 
blood  during  life,  as  in  cases  of  jaundice  ;  but  it  take:i 
place  also  when  there  is  no  reason  to  suppose  that  bile 
is  mixed  with  the  blood. 


Aneurysm  of  the  Heart. 

It  sometimes  happens,  although  I  believe  very 
rarely,  that  the  heart  becomes  aneurysmal.  This 
disease  consists  in  a  part  of  it  being  dilated  intoa  pouch, 
which  is  commonly  more  or  less  filled  \x\\\\  coagulat- 
ed blood.     Of  this  disease  I  have  only  seen  one  \n- 

D 


C     26     ] 

stance.  The  apex  of  the  left  ventricle  was  dilated 
into  a  pouch  large  enough  to  contain  a  small  orange, 
was  much  thinner  than  in  the  healthy  structure,  and 
was  lined  with  a  thick,  white)  opaque,  membrane. 
There  was  hardly  contained  in  it  any  coagulated 
blood;  but  the  quantity  of  the  coagulated  blood,  in 
an  aneurysm,  depends  commonly  on  the  size  of  the 
bag. 

This  disease  most  probably  arose  from  the  muscu- 
lar structure  at  the  apex  of  the  ventricle  becoming 
wreakcr  than  in  any  other  part,  so  that  when  the  ven- 
tricle contracted  upon  the  blood,  it  was  pushed  against 
the  weakened  part,  which  was  not  fully  able  to  resist 
its  impetus,  and  therefore  was  gradually  dilated.— 
Had  the  strength  of  the  apex  of  the  left  ventricle  been 
in  due  proportion  to  that  of  the  other  parts,  it  would 
seem  impossible  that  the  aneurysmal  swelling  should 
ever  have  taken  place. 

Aneurysm  of  the  Arch  ofttie  Aorta. 

The  most  frequent  situation  of  aneurysm  within  the' 
cavity  ofthe  thorax,  is  at  the  arch  of  the  aorta.  In 
this  disease  the  arch  of  the  aorta  is  much  enlarged  be- 
yond its  usual  size,  sometimes  forming  an  uniform 
tumour  ;  at  other  times  there  are  smaller  aneurysmal 
swellings  rising  out  of  the  larger  one.  This  enlarge- 
ment of  the  artery,  if  very  considerable,  is  more  or 
less  filled  with  coagulated  blood,  which  is  disposed  in 
concentric  laminse.  The  coats  of  the  dilated  artery 
are  nearly  of  the  same  thickness  with  those  in  its  nat- 
ural state  ;  and  therefore  in  proportion  as  the  swel- 
ling increases,  new  matter  must  be  deposited  in  the 
coats  of  the  artery.  This  new  matter  would  seem  to 
be  deposited  with  a  view  to  prevent  the  artery  from 
being  so  soon  ruptured  as  it  would  be  otherwise,  and 
is  formed  by  the  action  of  the  vasa  vasorum.  A  por- 
tion of  the  new  matter  may  perhaps  also  be  formed 
by  the  action  of  the  parts  immediately  in  contact  with 
the  arterv. 


t     27     ] 

The  coats  of  the  artery,  both  at  the  place  where 
the  aneurysm  is  formed,  and  near  it,  are  considerably 
altered  from  their  natural  structure.  They  are  more 
readily  divisable  into  different  layers,  than  where  tlic 
artery  is  sound,  and  have  often  formed  in  them  spots 
of  bony  matter.  These  spots  arc  frequently  of  a  yel- 
lowish colour,  and  are  formed  either  in  the  internal 
membrane  of  the  artery,  or  immediately  behind  it. 

The  coats  of  the  artery  in  the  neighborhood  of  the 
aneurysm,  are  often  found  to  be  very  irregular  in 
their  texture,  being  in  some  places  transparent  and 
thin,  in  others  thick  and  opaque  ;  and  there  is  some- 
times the  appearance  of  a  double  internal  membrane. 
The  same  sort  of  structure  is  also  to  be  found  in  the 
coats  of  the  aneurysm  itself.  The  arteries  near  an 
aneurysm  arc  diseased  to  a  greater  or  less  extent  in 
different  persons  ;  but  I  do  not  recollect  one  instance 
in  which  they  were  totally  free  from  disease. 

The  disease  sometimes  ends  fatally,  by  the  enlarg- 
ed artery  bursting,  and  the  blood,  escaping  into  the 
cavity  of  the  pericardium  ;  but  it  very  often  has  a 
further  progress  ;  the  swelling  of  the  aneurysm  grad- 
ually increases,  till  at  length  it  presses  against  the 
sternum,  and  the  cartilaginous  extremities  of  some 
of  the  ribs.  This  pressure  occasions  a  portion  of  the 
sternum  and  the  ribs  to  be  absorbed,  and  the  tumour 
is  thereby  perceived  externally.  The  absorption  of 
the  sternum  and  ribs  goes  on  very  gradually,  and  is 
not  accompanied  with  the  formation  of  pus.  The  tu- 
mcur  gradually  increases  in  size,  till  perhaps  it  is  as 
large  as  a  child's  head  at  birth  ;  a  part  of  the  skin  be- 
comes in  some  measure  dead,  and  cracks  from  disten- 
tion at  the  highest  point  of  the  tumor  ;  a  portion  of  the 
coagulated  blood  is  forced  out  by  the  impetus  of  the 
circulation,  and  the  person  is  cut  off  instantaneously. 
The  blood  sometimes  oozes  out  slowly,  and  the  per- 
son sinks  gradually  under  its  loss. 

Aneurysms  at  the  arch  of  the  aorta,  as  well  as  in 
every  other  part  of  the  arterial  system,  arise  from  the 
jsoats  of  the  artery  being  previously  diseased,  whicU 


[     28     ] 

are  thereby  unable  to  resist  sufficiently  the  impetus 
of  blood  that  strikes  against  them.  This  is  obvious, 
both  from  the  diseased  structure  of  the  coats  of  an 
aneurysm  itself,  and  of  the  artery  in  its  neighbour- 
hood. 

I  have  also  found  very  frequently,  diseased  appear- 
ances in  the  arch  of  the  aorta,  which  had  not  advanc- 
ed far  enough  to  produce  aneurysm.  These  consist 
in  little  white  opaque  spots  being  formed  in  the  inner 
membrane  of  the  artery,  and  in  its  coats  being  more 
-easily  separable  from  each  other  than  in  the  healthy 
state. 

The  reason  why  aneurysms  take  place  more  fre- 
quently in  the  arch  of  the  aorta,  than  in  any  other 
part  of  the  arterial  system,  is  its  curvature,  which  ex- 
poses it  to  the  full  impetus  of  the  blood  propelled  by 
the  strength  of  the  left  ventricle.  Aneurysms  hardly 
ever  happen  in  the  pulmonary  artery,  because  there 
5s  no  arch  formed  by  the  pulmonary  artery,  and  the 
blood  readily  passes  by  two  large  branches  into  the 
substance  of  the  lungs. 

Aneurysms  in  the  arch  of  the  aorta,  as  well  as  in 
every  other  part  of  the  arterial  system,  happen  much 
more  rarely  in  women  than  in  men.  This  arises  from 
two  causes.  The  one  is,  that  women,  from  their 
sedentary  life,  are  less  liable  to  an  increased  impetus 
of  blood,  occasioned  by  excited  circulation  ;  the  oth- 
er is,  that  the  arteries  in  this  sex  appear  to  be  less 
liable  to  these  diseased  alterations  of  structure,  which 
predispose  to  aneurysm. 

Ossification  of  the  Coronary  Arteries  of  the  Heart. 

The  coronary  arteries  are  occasionally  ossified  in  a 
greater  or  less  degree.  This  state  of  them  is,  I  bd- 
lieve,  generally  accompanied  with  ossified  portions  of 
the  aorta  at  its  origin,  and  sometimes  With  ossifica- 
tion of  the  semi-lunar  valves. 


C     29     1 


Ossification  of  the  Semi-lunar  Valves. 

The  three  semi-lunar  valves  at  the  origin  of  the 
aorta,  or  of  the  pulmonary  artery,  are  often  found 
diseased.  The  disease  very  commonly  consists  in 
the  deposition  of  a  bony  or  earthy  matter,  and  would 
seem  to  be  formed  by  a  morbid  action  of  some  very 
minute  vessels  which  are  distributed  through  the  sub- 
stance of  the  valves.  These  vessels  are  so  small,  as 
not  to  contain,  in  .their  natural  state,  the  red  globules 
of  the  blood. 


Semi-lunar  Valves  thick  and  opaque. 

It  frequently  happens  that  the  semi-lunar  valves 
are  considerably  thickened,  and  of  an  opaque  white 
colour  :  in  this  case,  the  coats  of  the  artery  in  the 
neighbourhood,  I  believe,  are  commonly  thickened 
and  diseased. 


Rupture  of  the  Valves. 

There  is  a  preparation  in  Dr.  Hunter's  collection, 
where  one  of  the  semi-lunar  valves  is  thickened,  hav- 
ing at  the  same  time  little  tenacity,  and  in  which  a 
considerable  rupture  had  taken  place.  It  is  very  rare 
that  such  an  occurrence  happens,  and  in  the  present 
instance  the  rupture  was  so  large,  that  I  believe  it 
must  have  proved  almost  immediately  fatal. 

Valves  between  the  Auricles  and  the  Ventricles  ossified. 

The  valvular  apparatus  between  the  auricles  and 
ventricles,  is  liable  to  the  formation  of  bony  and  earthy 
matter  in  it,  as  are  also  the  valves  which  are  situated 
at  the  origin  of  the  two  large  arteries,  but  by  no 
means  so  frequently.     What  this  depends  upon,  it 


C   5o   j 

is  very  difficult  to  determine.  These  valves  may  per- 
haps be  considered  as  belonging  more  to  the  venal 
than  the  arterial  system,  and  it  is  certain  that  ossifi- 
cation takes  place  very  seldom  in  veins,  although  ve- 
ry often  in  arteries. 


The  same  Values  thick  and  opaque. 

The  valvular  apparatus  between  the  auricles  and 
ventricles  is  also  occasionally  thickened,  having 
lost  all  its  transparency,  and  having  an  opaque  white 
colour.  The  chordae  tendinrae  likewise  become 
thicker  than  natural  ;  and  the  internal  membrane 
lining  the  ventricles  is  frequently  at  the  same  time  a 
good  deal  thickened,  appearing  like  a  firm  white  mem- 
brane. Under  such  circumstances  the  heart  is  often 
found  to  be  considerably  enlarged  beyond  its  usual 
size. 

I  have  also  seen  the  valvular  apparatus  between 
the  auricle  and  the  ventricle,  in  a  state  of  inflammation, 
and  covered  with  a  layer  of  coagulable  lymph  :  but 
this  I  believe  to  be  very  uncommon. 


Rupture  of  the  Heart, 

It  sometimes  happens,  and  I  believe  chiefly  in 
those  who  are  advanced  in  life,  that  the  heart  at  some 
part  becomes  thinner,  and  upon  any  great  exertion 
bursts.  The  blood  escapes  into  the  cavity  of  the  per- 
icardium, and  the  person  is  instantly  destroyed. 

Of  this  accident  I  have  one  instance  only ;  but  have 
heard  from  the  best  authority  of  another.  They  both 
happened  to  men  ;  and  I  mention  this  circumstance, 
because  men  appear  to  be  more  subject  to  diseases  of 
the  heart  and  blood  vessels  than  women.  It  is  proba- 
ble that  persons  dying  from  this  cause  have,  on  account 
of  the  suddenness  of  their  death,  been  supposed  to 
die  of  apoplexy. 


t     31     ] 


Blood  in  the  Pericardium,  without  a  Rupture  of  the 

Heart. 

Cases  have  occurred,  although  very  rarely,  in 
which  a  large  quantity  of  blood  has  been  accumula- 
ted in  the  cavity  of  the  pericardium,  but  where  no 
rupture  could  be  discovered  after  the  most  diligent 
search,  either  in  the  heart  itself,  or  in  any  of  its  ves- 
sels. This  appears  very  wonderful,  and  not  at  all 
what  any  person  would  expect  a  priori.  Upon  the 
supposition  of  there  being  no  rupture,  two  conjec- 
tures only  have  occurred  to  me  about  the  manner  in 
which  such  an  effect  has  taken  place,  and  they  are 
both  attended  with  considerable  difficulty. 

The  one  is,  that  the  vessels  upon  the  surface  of  the 
heart,  may  have  lost  a  part  of  the  compactness  of 
their  texture,  so  that  the  blood  may  have  escaped 
through  their  coats  by  transudation.  The  other  is, 
that  blood  may  have  been  thrown  out  by  the  extrem- 
ities of  the  small  vessels  opening  upon  the  surface, 
of  that  portion  chiefly  of  the  pericardium  which  forms 
the  immediate  covering  of  the  heart,  from  their  orifi- 
ces having  been  to  a  very  uncommon  degree  re. 
laxed.* 


Malformation  cf  the  Heart. 

It  also  happens,  although  I  believe  very  rarely,  that 
a  heart  is  so  imperfectly  formed  as  to  allow  of  life  be- 
ing continued  for  some  length  of  time,  in  a  very  un- 
comfortable state,  but  to  be  ultimately  the  cause  of 
death.  There  are  two  cases  of  this  sort  described 
by  the  late  Dr  Hunter, |  and  there  is  one  specimen  of 
this  malformation  preserved  in  his  collection.  The 
malformation  preserved  in  the  collection,  consists  in 

*  See  Med.  Observations,    Vol.  4.  p.  330.      Memoirs  cf  Med.  Societr. 
Vol  1.  p.  2.53. 
t  Vid.  M<dical  Obtervaiions,  Vol.  6.  p.  »1. 


[     32     ] 

the  right  ventricle  of  the  heart  being  extremely 
small,  and  the  pulmonary  artery  being  verX  small 
also  which  arises  from  it.  At  its  origin  from  the  right 
ventricle  it  is  completely  impervious.  The  ductus 
arteriosus  is  open,  but  forms  likewise  a  small  canal, 
and  terminates  in  the  left  branch  of  the  pulmonary 
artery.  The  right  auricle  is  larger  than  it  naturally 
is,  from  the  frequent  accumulation  of  blood  in  it  ; 
and  the  communication  between  the  two  auricles,  by 
means  of  the  foramen  ovale,  is  much  larger  than  usual. 
The  child,  in  whom  this  malformation  was  found,  had 
its  skin  of  a  very  dark  colour,  and  had  very  laborious 
respiration,  with  violent  action  of  the  heart.  It  lived 
only  thirteen  davs. 


In  another  case  related  by  Dr.  Hunter,  the  pul- 
monary artery  was  very  small,  especially  at  its  origin, 
and  there  was  a  deficiency  in  the  septum  cordis,  at 
the  basis  of  the  heart,  large  enough  to  allow  a  small 
thumb  to  pass  through  it.  The  person  in  whom  this 
malformation  of  the  heart  was  found,  lived  about 
thirteen  years.  He  never  had  a  fresh  complexion, 
but  it  Mas  always  dark,  or  tending  to  black.  He 
was  often  seized  with  fits,  especially  when  there  was 
any  hurry  upon  his  spirits,  or  there  had  been  any 
brisk  motion  of  his  body. 

It  is  obvious  that  in  these  deviations  from  the  nat- 
ural structure,  too  small  a  quantity  of  blood  must 
pass  through  the  lungs  to  receive  the  benefit  of  respi- 
ration, and  that  this  will  be  more  or  less  according  to 
the  degree  of  the  deviation.  The  blood  will  from 
this  cause  be  of  a  dark  colour,  as  it  is  well 
known  that  it  receives  the  florid  hue  from  the  influ- 
ence of  the  air  upon  it  in  the  lungs.  Hence  the  col- 
our of  the  skin  must  be  necessarily  dark,  and  this 
will  be  increased  when  the  blood  is  accumulated 
more  than  usual  in  the  veins.  It  is  natural  to  think 
that  in  such  structures  of  the  heart,  the  circulation 
will  be  carried  on  with   much  more  difficulty    whey 


[     S3     ] 

it  is  excited  beyond  its  usual  standard.  This  may 
even  be  supposed  to  be  encreased  to  such  a  degree  as 
to  produce  fits,  which  happened  in  one  of  the  Cases. 


There  is  an  example  also  in  Dr.  Hunter's  collec- 
tion of  a  heart  from  a  child,  which  had  a  hole  in  the 
septum  ventricujorum  at  the  basis  of  the  heart,  large 
enough  to  allow  a  goose  quill  readily  to  pass  through 
it.  The  child  was  still  born  at  six  months,  and  the 
hole  in  the  septum  evidently  arose  from  original  mal- 
formation. This  too  is  described  by  Dr.  Hunter,  in 
the  sixth  volume  of  the  Medical  Observations.  An 
instance  somewhat  similar  to  this  has  been  published 
by  Dr.  Pultcney,  in  the  third  volume  of  the  Medical 
Transactions  ;  the  person  to  whom  this  monstrosity 
belonged,  lived  to  near  fourteen  years  of  age. 


A  very  singular  malformation  of  the  heart,  in  a 
child  about  two  months  old,  came  some  time  ago  in- 
to my  possession,  which  I  shall  describe  in  this 
place.  The  aorta  in  this  heart  arose  out  of  the  right 
ventricle,  and  the  pulmonary  artery  out  of  the  left. 
There  was  no  communication  between  the  one  ves- 
sel and  the  other,  except  through  the  small  remains 
of  the  ductus  arteriosus,  which  was  just  large  enough 
to  admit  a  crow  quill.  The  foramen  ovale  was  a  lit- 
tle more  closed  than  in  a  child  newly  born.  The 
heart  was  of  the  common  size  for  a  child  of  two 
months  old,  and,  except  for  the  circumstances  which 
have  been  stated,  had  nothing  remarkable  in  its  struc- 
ture. In  this  child  a  florid  blood  must  have  been  al- 
ways circulating  between  the  lungs  and  the  left  sid^ 
of  the  heart,  except  for  the  admixture  of  the  dark 
blood  which  passed  through  the  small  communication 
of  the  foramen  ovale  ;  and  a  dark  blood  must  have 
been  always  circulating  between  the  right  side  of  the 

E 


E   34   2 

heart  and  the  general  mass  of  the  body,  except  for 
the  very  small  quantity  of  florid  blood  which  passed 
into  the  aorta  by  the  remains  of  the  ductus  arteriosus. 
Life  must,  therefore,  have  been  supported  for  a  very 
considerable  length  of  time  with  hardly  any  florid 
blood  distributed  over  the  body.  I  regret  extremely 
that  I  have  only  been  able  to  collect  a  very  imperfect 
account  of  the  child  when  alive.  The  child  had  a 
most  unusually  livid  skin,  which  arose  from  the  very 
small  proportion  of  the  florid  blood  in  the  general  cir- 
culation. The  surface  of  the  child's  body  felt  colder 
than  that  of  a  child  properly  formed  and  in  good 
health  ;  the  respiration  was  natural.  When  any  sim- 
ilar malformation  shall  occur,  it  could  be  wished  that 
the  heat  of  the  surface  of  the  body,  and  of  the  inter- 
nal parts,  were  measured  accurately  by  a  thermom- 
eter. The  heat  of  the  internal  parts  will  be  most 
conveniently  measured  by  putting  a  small  thermome- 
ter into  the  rectum.* 


Heart  enlarged. 

The  heart  is  sometimes  found  very  much  enlarged 
in  its  size,  but  without  any  apparent  disease  in  its 
structure.  The  muscular  parietes  are  generally  as 
thin  and  sometimes  even  thinner  than  in  a  heart  of 
the  common  size.  Its  cavities  are  filled  with  blood,, 
partly  fluid,  and  partly  concreted  into  a  loose  coagu- 
lura. 


Hydatids  adhering  to  the  Heart. 

Hydatids*)*  have  occasionally  been  found  adhering 
to  the  heart ;  but  I  have  not  met  myself  with  any  in- 

*  Thft  very   singular  malformation  of  tlie  heart  was  given  to  rne  by  Dr. 
WoUaston,  of  St'.  Ed  ,  w ho  took  much  trouble  in  endeavouring,  to. 

collect  information  about  the  child,  but  without  the  desired .succes*, 

t  See  Mcrgngni,  Epist,  XXV.  Art.  *5- 


[     35     ] 

fiances  of  this  sort.  They  do  not  appear  to  be  of  the 
same  kind  in  every  part  of  the  body  ;  but  their  na- 
ture will  be  explained  particularly,  when  I  come  to 
describe  the  diseased  appearances  of  the  liver  and 
kidneys. 


A  Portion  of  the  Heart  bony,  or  earthy. 

A  portion  of  the  heart  has  been  observed  to  be 
converted  into  bone.*  Earthy  matter  has  also  been 
found  deposited  in  the  muscular  substance  of  the 
heart. f  Neither  of  these  appearances  has  come  un- 
der my  own  observation,  and  they  are  to  be  looked 
upon  as  very  uncommon. 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the 
licart  are  very  much  the  same  with  those  which  be- 
ipng  to  inflammation  of  the  pericardium,  viz.  symp- 
tomatic fever  ;  pain  in  the  situation  of  the  heart  ;  pal- 
pitations ;  an  irregular  pulse  ;  cough ;  difficulty  of 
breathing  ;  and  often  syncope.  It  would  seem  prob- 
able that  the  last  symptom  is  principally  connected 
with  inflammation  of  the  substance  of  the  heart,  and 
perhaps  it  may  not  be  found  in  a  pure  inflammation  of 
the  pericardium.  The  two  diseases,  however,  are 
very  commonly  blended  .together. 


The    symptoms    which     attend  aneurysm  of  the 

•  See  Morgagni,  Episb  XXVII.  Art.  16.    See  also  Medical  Comrr. mu- 
tations, Vol,  1.  p,  238. 

t  See  Bonctus,  Tcm.  1,  p.  S^O,  and  p.  815. 


[     30     ] 

heart,  are  similar  to  those  which  belong  to  aneurysm 
of  the  arch  of  the  aorta. 


The  chief  symptom  which  attends  aneurysm  of  the 
arch  of  the  aorta,  in  an  early  stage  of  the  disease,  is  a 
strong  pulsation  in  the  chest.     The  pulsation  is  com- 
luonlv  at  the  same  time  visible  to  the  eye,  when  the 
chest  is  exposed  to  view.     Ave  are  not   to  conclude, 
however,  from  this  symptom  only,  that  there  is  cer- 
tainly an  aneurysm.     I  have  felt  the  same  kind  of  pul- 
sation in  other  cases  ;  as  for  instance,  where  the  pe- 
ricardium was  found  strongly  to  adhere  to  the  heart ; 
where  was  a  slight  inflammation  upon  the   surface  of 
the  heart,  with  a  little  more   water  than  usual  in  the 
pericardium  ;  and   where  a  morbid  enlargement  had 
taken  place  in  the  heart  without  any  aneurysmal  swel- 
ling.    But  when  an  aneurysm  of  the  arch  of  the  aor- 
ta has  advanced  to  a  large  size,  a  tumour   begins  to 
be  formed  externally,  accompanied  with  a  strong  pul- 
sation.    This  I  believe  belongs   only   to   aneurysm, 
and  becomes  the  most  decided  characteristic  of  this 
disease.     The  pulse  at  the  wrist  in  aneurysm  of  the 
arch  of  the  aorta  is  sometimes  irregular  ;  but  often  no 
irregularity   can   be   felt   in  it.     There   is  Generallv 
more  or  less  of  pain  in  the  aneurysmal  tumour,  or  in 
some  other  part  of  the  chest.     Difficulty  of  breathing 
upon  taking  exercise  also  commonly  attends  this  dis- 
ease, which  is  increased  in  proportion  as  the  disease 
advances. 


"Ossification  of  the  coronary  arteries  would  seem  to 
produce,  or  to  be  intimately  connected  with  the  symp- 
toms which  constitute  angina  pectoris.  These  con- 
sist of  a  pain  which  shoots  from  the  middle  of  the 
sternum  across  the  left  breast,  and  passes  down  the 
left  arm,  to  near  the  elbow,  sometimes  even  to  the 
ivvist  of  the  left  hand.     In  a  few  cases  the  pain  has 


[     37     ] 

been  known  to  shoot  across  the  right  breast  as  well 
as  the  left,  and  to  pass  clown  the  right  arm,  either  to 
near  the  elbow  or  the  wrist.  It  is  excited  by  walk- 
ing, more  especially  up  an  ascent,  and  by  any  con- 
siderable emotion  of  the  mind.* 


The  symptoms,  which  are  produced  by  a  diseased 
alteration  in  the  structure  of  the  valves  of  the  heart, 
are  not  so  distinct  as  to  be  clearly  discriminated  in 
practice.  They  consist  of  difficulty  of  breathing  ; 
of  occasional  palpitations  ;  of  a  weak  and  often  an  ir- 
regular pulse  ;  and  in  some  cases  there  has  been  ob- 
served a  disposition  to  fainting.  No  observations 
have  yet  been  made  by  which  practitioners  may  be 
led  to  conjecture  what  set  of  valves  is  diseased. 


The  symptoms  which  have  been  noticed  as  attend- 
ing a  gradual  effusion  of  blood  into  the  pericardium, 
are  a  great  degree  of  faintness  ;  difficulty  of  breathing ; 
much  anxiety  and  oppression;  a  dull  pain,  and  a 
sense  of  weight  behind  the  sternum.  To  these  a  cold 
clammy  sweat  has  been  observed  to  succeed,  and  to 
spread  over  the  body. 


When  the  heart  is  mnch  enlarged,  the  disease  is 
attended  with  palpitations.  These  may  not  only  be 
felt  by  the  hand,  when  applied  to  the  left  side,  but 
may  often  be  perceived  by  the  eye,  even  when  the 
chest  is  covered  with  the  ordinary  clothing.  In  one 
or  two  instances,  I  have  known  the  pulse  at  the  wrist 
to  beat  with  an  unusual  degree  of  vigour,  but  much 
more  commonly  the  pulse  is  feeble  and  irregular. 
The  muscular  parietes  of  the  heart   being  generally 

*  See  an  excellent  treatise  upen  this  subject  by  Dr.  Parry. 


[     38     ] 

thin  in  proportion  to  the  enlarged  size  of  its  cavities, 
the  heart  has  little  power  to  propel  an  increased  quan- 
tity of  blood  into  the  more  distant  branches  of  the  ar- 
terial system.  At  times  there  is  much  difficulty  of 
breathing  ;  and  there  is  a  purplish  hue  of  the  cheeks 
and  lips.  This  colour  is  more  deep  in  its  tinge  at  one 
time  than  another,  according  as  the  blood  has  been 
transmitted  with  more  or  less  difficulty  through  the 
lungs.  The  causes  which  produce  a  morbid  growth 
of  the  heart  are  but  little  known  ;  one  of  them  would 
seem  to  be  rheumatism  attacking  this  organ.* 


The  symptoms  produced  by  the  formation  of  hyda- 
tids, in  the  cavity  of  the  pericardium  are  not  dis- 
tinctly known  ;  but  they  cannot  be  supposed  to  differ 
much  from  those  of  water  in  the  pericardium.  In  a 
case  related  by  Morgagni,  the  patient  was  subject  to 
faintins 


'£>• 


When  a  part  of  the  heart  is  converted  into  an  earthy 
matter  or  bone,  no  morbid  symptoms  whatever  have, 
in  some  cases,  been  observed  ;  and  in  others  there 
has  been  palpitation  of  the   heart,  with  difficulty  of 


breathing. 


Dr.  Pitcairn  has  observed  this  in  several  cases. 


C   ^    1 


CHAP.  III. 


DISEASED    APPEARANCES    IN     THE     CAVITY    OF 
THE     THORAX. 


Inflammation. 


T 


HE  pleura,  or  the   membrane  which  lines  the 
cavity  of  the  thorax,  is  very  subject  to  inflammation. 
This   may  take  place  at  any  period  of  life,  but  it  is 
more  frequent  at  the  age  when  the    body  is  just  arri- 
ved at  the  adult   state,  and  all  its  actions  are  carried 
on  with  vigour,  than  either  in  childhood  or  in  advan- 
t  ed  age.     The  pleura  appears  to  be   more  liable  to 
inflammation  than  any  membrane  lining  those  cavities 
which  have  no  external  opening  ;  as  the  peritonaeum, 
the  tunica  vaginalis  testis,  and  some   others.     This 
may  arise  from  the  following  causes  :     The  branches 
of  the  intercostal  vessels,  which  are  very  numerous, 
piercing  through  the  substance  of  the  intercostal  mus- 
cles, communicate  a  good dealby  anastomosis,  with  the 
external  vessels  on  the  sides  of  the  chest.  Hence  what- 
ever may  act  upon  these  external  vessels  so  as  to  excite 
contraction  in  them,  may  be  supposed  capable  of  produ- 
cing an  accumulation  of  blood,  as  well  as  an  increased 
action  in  the  inner  branches  of  the  intercostals,  many 
of  which  arc  distributed  upon   the   pleura.     Many 
of  the  inhabitants  of  this  country,  from  their  mode  of 
dress,  have  their  chests  much  exposed  to  the  ii 
ence  of  a  cold  and  very  uncertain  climate,  and  he 
the  blood  is  frequently  thrown  inwards  into  the  small 
vessels  ramifying  upon  the  pleura.    For  these  reasons 
probably  the  pleura  is  more  liable  to  inflammation  than 


[     40     ] 

other  membranes  investing  cavities  which  have  no 
external  opening.  This  is  so  much  the  case,  that 
one  can  hardly  examine  the  chest  of  any  person  who 
has  arrived  at  the  adult  state,  without  perceiving 
more  or  less  the  traces  of  a  present  or  former  inflam- 
mation. 

When  the  pleura  is  inflamed,  it  becomes  thicker 
than  it  is  naturally,  and  in  some  degree  pulpy.  There 
are  also  interspersed  through  it  a  great  number  of 
very  small  vessels  containing  florid  blood,  and  a  lay- 
er of  coagulable  lymph  is  at  the  same  time  thrown 
out  upon  its  surface.  This  layer  is  sometimes  very 
thin,  and  at  other  times  of  considerable  thickness. 
It  is  either  smooth  upon  its  surface,  or  it  throws  out 
many  small  flocculi,  which  exhibit  the  appearance  of 
a  rich  lace-work.  A  serous  fluid  is  also  poured  into 
the  cavity  of  the  thorax,  in  which  are  floating  many 
small  broken  lam  in  as  of'  the  coagulable  lymph  ;  and 
there  is  occasionally  some  mixture  of  pus. 

The  coagulable  lymph,  covering  the  pleura  which 
forms  the  external  membrane  of  the  lungs,  frequent- 
ly adheres  to  that  which  covers  the  pleura  that  is  re- 
flected on  the  inside  of  the  parietes  of  the  chest,  either 
in  small  portions,  or  by  extended  surfaces.  Upon 
such  occasions  I  have  sometimes  been  able  to  trace  the 
gradual  change  of  the  adhesion,  from  the  state  of  co- 
agulable lymph  to  that  of  cellular  membrane.  This 
coagulable  lymph  may  be  shewn  to  be  vascular  by  in- 
jection, as  we  have  already  mentioned  in  the  inflam- 
mation of  the  pericardium.  When  the  pleura  is  in- 
flamed which  covers  the  lungs,  the  substance  of  the 
latter  is  frequently  inflamed  to  some  depth. 


Adhesions  in  the  Cavity  of  the  Thorax. 

Adhesions  are  often  found  between  that  portion  of 
the  pleura  which  covers  the  lungs,  and  that  other 
portion  of  it  which  lines  the  ribs,  the  intercostal  spa- 
ces, and  the  convex  surface  of  the  diaphragm,  while 


[     41     ] 

there  is  no  sign  whatever  of  present  inflammation. 
These  adhesions  are  often  partial,  and  then  they  are 
most  commonly  to  be  found  at  the  upper  and  posteri- 
or part  of  the  chest ;  but  they  are  sometimes  extend- 
ed over  the  whole  cavity.  They  either  connect  the 
parts  together  closely,  in  which  case  they  often  con- 
sist of  a  firm  thick  membrane  ;  or  they  connect  them 
loosely,  and  then  they  consist  of  a  soft  spongy  mem- 
brane, which  exactly  resembles  the  common  cellular 
membrane  of  the  body.  Such  adhesions  are  the  con- 
sequence of  inflammation,  and  are  perhaps  the  most 
common  morbid  appearance  to  be  found  in  dead 
bodies. 


Empyema. 

Pus  is  not  unfrequently  accumulated  in  the  cavity 
of  the  chest,  forming  the  disease  called  empyema. 
This  may  either  arise  from  the  blood  vessels  of  the 
pleura  being  in  such  a  state  of  inflammation  as  to  form 
pus,  or  from  the  bursting  of  some  abscess  in  the 
lungs,  so  as  to  evacuate  its  pus  into  the  cavity  of  the 
thorax.  When  pus  is  formed  by  an  inflamed  state  of 
the  pleura,  there  is  no  occasion  for  ulceration  to  take 
place.  The  pleura  is  found  entire,  but  is  covered 
with  a  layer  of  the  coagulable  lymph.  This  fact  has 
been  long  ago  ascertained  by  the  late  Dr.  Hunter. 
The  formation  of  the  pus  depends  on  a  certain  state 
of  action  in  the  vessels  of  the  pleura,  or  more  proba- 
bly of  the  layer  of  the  coagulable  lymph  which  covers 
it.  The  p'.is  may  either  occupy  the  whole  of  one  of  the 
cavities  of  the  chest,  or  may  be  confined  to  a  part  of 
it  by  adhesions  taking  place  between  the  lungs  and 
the  pleura,  which  invests  the  ribs  and  the  intercostal 
spaces.  When  pins  is  evacuated  into  the  cavity 
of  the  chest  by  the  bursting  of  an  abscess  in  the 
lungs,  it  is  almost  always  confined  within  certain 
limits  by   adhesions.      In  cases  of  empyema,    for 


[     42     3 

the  most  part,  there  is  not  any  particular  appear- 
ance of  the  chest  observable  on  the  outside  :  there  is 
sometimes  however  a  fullness  to  be  perceived  exter- 
nally on  the  side  where  the  matter  is  accumulated, 
and  even  occasionally  an  evident  swelling  between 
two  of  the  ribs,  as  of  matter  pointing.  Ulceration 
has  also  been  known  to  take  place  in  one  or  more  of 
the  intercostal  spaces,  so  that  the  matter  has  been 
evacuated  externally.  There  is  an  example  in  Dr. 
Hunter's  collection,  where  the  matter  had  been  evac- 
uated from  the  chest  by  a  good  many  openings  in  the 
intercostal  spaces. 


Hydrothorax. 

A  watery  fluid  is  not  uncommonly  found  in  one  or 
both  cavities  of  the  chest,  forming  the  disease  called 
hydrothorax.  It  is  often  attended  with  the  accumu- 
lation of  water  in  other  parts  of  the  body,  especially 
in  the  pericardium,  and  the  cellular  membrane  of  the 
lower  extremities.  The  fluid  in  hydrothorax  is  com- 
monly of  a  brown  ©r  yellowish  colour,  but  occasion- 
ally has  a  reddish  colour,  arising  from  the  mixture  of 
the  red  globules  of  blood.  It  resembles  in  its  prop- 
erties the  serum.  It  is  found  to  vary  a  good  deal  in 
quantity  in  different  cases,  sometimes  amounting  on- 
ly to  a  few  ounces,  and  at  other  times  to  several  quarts. 
When  it  is  accumulated  in  very  large  quantity  in 
either  side  of  the  chest,  that  side  appears  to  be  fuller 
to  the  eye  externally  ;  and  when  the  cavity  is  laid  op- 
en after  death,  the  lungs  on  that  side  are  found  more 
or  less  compressed.  I  have  seen  a  lung  so  compres- 
sed, as  not  to  be  larger  than  the  closed  fist. 

Water  is  likewise  found  in  the  cavity  of  the  chest 
where  there  arc  considerable  adhesions.  This  shews 
that  a  good  deal  of  inflammation  had  formerly  taken 
place,  which  had  probably,  by  throwing  out  a  consid* 


C     43     ] 

arable  quantity  of  serum,  laid  the   foundation  of  the 
hydrothorax.* 

The  Pleura  almost  dry. 

In  opening  into  the  cavity  of  the  chest,  there  is 
commonly  found  a  good  deal  of  moisture  upon  the 
surface  of  the  pleura.  This  is  intended  to  lubricate 
the  surface  of  the  cavity  of  the  chest,  for  the  more 
easy  motion  of  the  lungs  within  it.  Sometimes, 
however,  I  have  seen  the  moisture  in  very  small 
quantity,  so  that  the  pleura  might  almost  be  said  to 
be  dry.  This  was  occasioned  either  by  a  deficiency 
in  the  action  of  the  exhalant  arteries  of  the  pleura,  or 
bv  an  increased  action  of  its  absorbents. 


Ossification  of  the  Pleura. 

It  sometimes  happens,  although  I  believe  rarely, 
that  a  portion  of  the  pleura  is  converted  into  bone. 
This  consists  of  a  thin  plate  and  sometimes  extends 
over  a  considerable  surface  of  the  pleura.  In  all  the 
cases  which  I  have  seen,  the  bony  matter  seemed  to 
me  to  be  exactly  like  ordinary  bone.  I  have  never 
seen  it  form  a  thick  irregular  knob,  but  always  a  thin 
plate.  The  cause  which  first  excites  this  diseased 
process  it  is  very  difficult  to  determine  ;  but  there 
can  be  no  doubt  that  the  bone  is  formed  by  the  small 
vessels  of  the  pleura,  which  secrete  bony  matter  from 
the  blood.  This  process  is  not  peculiar  to  th«  pleura, 
but  takes  place  in  almost  every  part  of  the  body  : 
I  believe,  however,  that  it  is  more  common  in  the 
pleura,  than  in  any  other  similar  membrane.  In  the 
cases  which  I  have  observed,  this  process  seemed 
not  to  have  been  attended  with  much  inconvenience. 
There  was  no  inflammation  found   in  the  pleura  sur- 

•  This  circumstance  is  illustrated  in  several  instances  by  Mr-  CruikshanVj 
•in  his  Treatise  upon  the  Absorbent  System.     See  3d  edivi  in,  p.  Hb. 


[     44     ] 

rounding  the  bone,  nor  in  the  substance  of  the  lungs 
under  it.  It  is  reasonable  to  think,  however,  if  the 
bone  were  to  grow  irregularly,  so  as  to  form  sharp 
processes,  that  it  might  excite  inflammation,  and  lay 
the  foundation  of  a  fatal  disease.* 


SYMPTOMS. 


The  symptoms  which  attend  inflammation  of  the 
pleura  are  very  wrell  ascertained.  There  is  more  or 
less  of  symptomatic  fever  ;  an  acute  pain  in  some 
part  of  the  chest,  more  commonly  in  the  side,  which 
is  increased  upon  inspiration  ;  a  great  difficulty  in  ly- 
ing upon  the  diseased  side  ;  difficult  respiration  ;  a 
cough,  which  at  first  is  dry,  but  is  afterwards  accom- 
panied with' a  secretion  and  expectoration  of  mucus 
from  the  inner  membrane  of  the  trachea  and  its 
branches. 

There  would  often  seem  to  be  slight  degress  of  in- 
flammation in  the  pleura,  where  the  symptoms  above 
stated  do  not  exist  at  all,  or  aie  so  obscurely  marked 
as  to  be  altogether  overlooked.  In  examining  the 
chest  of  adults  after  death,  it  rarely  happens  that  ad- 
hesions are  not  discovered  in  some  part  of  it,  uniting 
the  surface  of  the  lungs  to  the  pleura  which  lines  the 
parietes  of  the  chest.  The  marked  symptoms  of 
pleurisy,  however,  are  by  no  means  so  frequent.  It 
seems,  therefore,  probable,  that  slight  inflammations 
may  attack  the  pleura,  sufficient  however  to  throw 

*  A  casi  is  mentioned  by  Dr.  Soemmerring,  where  a  part  of  the  lungs 
was  found  intiamed  and  suppurated  under  an  ossification  of  the  pleura.  See 
Sojmrr.er.  Germ,  Translat,  of  the  Morbid  Anatomy,  p.  43. 


[     45     ] 

out  coagulable  lymph,  which,  is  afterwards  changed 
into  adhesions,  and  yet  that  persons  thus  affected 
shall  not  be  sensible  of  any  disease  in  the  chest.  ]f 
this  supposition  be  not  granted,  then  coagulable  lymph 
may  be  thrown  out  upon  the  surface  of  the  pleura, 
and  adhesions  be  formed  without  inflammation.  This 
conjecture  is  not  so  probable  as  the  other. 


Where  adhesions  in  the  chest  arc  lone;,  so  as  not 
to  impede  the  free  motion  of  the  lungs,  respiration  is 
not  sensibly  affected  by  them.  But  where  the  adhe- 
sions are  short,  tying  as  it  were  the  lungs  closely  to 
the  parietes  oi  the  chest,  and  more  especially  if  they 
be  extended  over  every  part  of  the  cavity,  then  res- 
piration is  difficult,  and  accompanied  with  a  cough, 
but  there  arc  no  symptoms  of  fever. 


Empyema  may  be  distinguished  with  a  good  deal 
of  certainty,  after  inflammation  of  the  pleura  or  of  the 
lungs,  by  rigors  having  taken  place,  by  a  remission 
of  the  pain,  by  the  cough  and  difficulty  of  breathing 
continuing,  and  by  the  person  being  able  to  lie  more 
easily  upon  the  diseased  side  than  the  oilier.  There 
is  sometimes  a  very  evident  enlargement  of  th«  side 
where  the  matter  is  accumulated. 


When  water  is  accumulated  in  the  chest,  it  can 
generally  be  sufficiently  distinguished  in  practice  by 

the  following  symptoms. 

There  is  great  difficulty  of  breathing,  and  the  pa- 
tient cannot  rest  in  bed  unless  the  head  and  the  upper 
part  of  the  trunk  be  more  or  less  elevated  from  the 
horizontal  posture.  The  sleep  is  often  suddenly  in- 
terrupted by  alarms  and  disagreeable  dreams  ;  the 
urine  is  in  very  small  quantity,  and  there  is  common- 
ly anasarca  of  the  legs.     The  pulse  is  generally,  but 


C     46     ] 

not  always,  irregular.  There  is  a  paleness  in  the 
countenance,  with  a  purple  hue  of  the  lips  and  of  the 
cheeks,  if  the  latter  should  happen  to  have  any  tinge 
remaining.  This  effect  is  produced  by  the  lungs  be- 
ing incapable  of  sufficiently  expanding  themselves  to 
receive  the  quantity  of  air  which  is  necessary  for  giving 
the  usual  florid  colour  to  the  blood  in  the  branches  of 
the  pulmonary  artery. 


When  ossification  of  the  pleura  is  of  small  extent,, 
respiration  cannot  be  affected  by  it ;  but  when  it  is 
large  it  must  produce  difficulty  of  breathing,  either 
by  preventing  the  full  expansion  of  the  lungs,  or  the 
free  motion  of  the  ribs,  according  to  its  situation  : 
Some  instances  are  known  of  respiration  being  injur- 
ed from  this  cause* 

Where  the  ossification  has  produced  inflammation 
of  the  pleura  and  lungs,  symptoms  of  inflammation 
will  take  place  as  above  described,  but  probably  in 
some  cases  there  may  be  peculiar  symptoms,  depend- 
ing chiefly  on  the  different  irritability  of  different  con- 
stitutions. In  one  case  there  were  paroxisms  of  con- 
vulsive difficulty  of  breathing,  palpitation  of  the 
heart,  a  quick  irregular  pulse,  and  a  distressing 
sense  of  instant  suffocation.* 

*  See  Mr.  Weldon's  Observations  in  Surgery,  p,  75  and  76. 


E     47     ] 


CHAP.  IV. 


DISEASED  APTEARANCES   OF  THE  LUNG  So 


Inflammation. 


I 


NFLAMATION  of  the  substance  of  the  lungs,  I 
believe,  seldom  takes  place  without  some  similar  af- 
fection of  the  pleura;  at  least  in  the  instances  which 
I  have  seen,  this  has  been  most  frequently  the  case. 
When  a  portion  of  the  lungs  is  inflamed,  its  spongy- 
structure  appears  much  redder  than  usual,  the  colour 
being  chiefly  florid  but  partly  of  a  darker  hue.  This 
arises  from  a  much  greater  number  of  small  vessels 
than  usual,  being  distributed  upon  the  cells  of  the 
lungs,  which  are  capable  of  admitting  the  red  globu- 
les of  the  blood.  There  is  also  an  extravasation  of 
the  coagulable  lymph  into  the  substance  of  the  lungs, 
and  sometimes  of  blood.  The  extravasated  blood  has 
been  said  upon  some  occasions  to  be  in  very  large 
quantity  ;  but  this  has  never  fallen  under  my  own 
observation. 

That  portion  of  the  lungs  which  is  inflamed  be- 
comes considerably  heavier  than  in  the  natural  state, 
from  the  accumulation  of  blood  in  its  vessels,  and  the 
extravasation  of  the  coagulable  lymph;  it  therefore 
commonly  sinks  in  water.  It  feels  like  a  solid  sub- 
stance when  pressed  by  the  fingers,  and  there  is  no 
crackling  of  air   a9  in  the   healthy  structure.     This 


[     48     ] 

however  will  be  more  or  less  marked,  according  to 
the  degree  of  the  inflammation. 

The  pleura  covering  the  inflamed  portion  of  the 
lungs  is  also  commonly  affected  with  inflammation  ; 
it  is  crowded  with  line  red  vessels,  and  has  generally 
lying  upon  it  a  layer  of  coagulable  lymph. 

This  inflamed  state  of  the  lungs  is  to  be  distinguish- 
ed from  blood  accumulated  in  some  part  of  them  after 
death  in  consequence  of  gravitation.  From  the  body 
lying  in  the  horizontal  posture  after  death,  blood  is 
often  accumulated  at  the  posterior  part  of  the  lungs, 
giving  them  there  a  deeper  colour,  and  rendering  them 
heavier.  In  this  case  there  will  be  found  no  crowd 
of  fine  vessels  filled  with  blood,  nor  any  other  mark 
of  inflammation  of  the  pleura.  Where  blood  too  is 
accumulated  in  any  part  of  a  lung  after  death,  from 
gravitation,  it  is  always  of  a  dark  colour  ;  but  where 
blood  is  accumulated  from  inflammation,  the  inflam- 
ed part  will  appear,  in  a  great  measure,  florid. 


Abscesses. 

It  is  very  common  to  find  abscesses  in  the  lungs. 
These  sometimes  consist  of  small  cavities  containing 
pus  gnd  at  other  times  the  cavities  arevery large  so  that 
the  greater  part  of  the  substance  of  the  lungs  has  been 
destroyed.  These  cavities  sometimes  communicate 
only  with  branches  of  the  trachea,  which  are  destroy- 
ed in  the  progress  of  the  ulceration  ;  at  other  times 
they  open  into  the  cavity  of  the  chest,  emptying  their 
contents  there,  and  forming  the  disease  which  is  call- 
ed empyema.  When  abscesses  are  deeply  seated  in 
the  substance  of  the  lungs,  the  pleura  is  commonly 
not  affected  ;  but  when  abscesses  are  formed  near  the 
surface,  it  is  almost  constantly  inflamed.  The  lungs 
round  the  boundaries  of  an  abscess,  when  it  has  arisen 
from  common  inflammation,  are  more  solid  in  their 
texture,  in  consequence  of  coagulable  lymph  being 
thrown  out  during  the  progress  of  the   inflammation. 


[     49     ] 

When  the  abscesses  are  scrofulous,  the  texture  of  the 
lungs  in  the  neighbourhood  is  sometimes  not  firmer 
than  usual,  but  presents  the  common  natural  appear- 
ance. This  I  believe  to  be  principally  the  case  when 
the  abscesses  are  small,  and  placed  at  a  considerable 
distance  from  each  other.  When  a  portion  of  the 
lungs  is  crowded  with  tubercles,  and  some  of  these 
are  converted  into  abscesses,  the  intermediate  sub- 
stance of  the  lungs  is  often  of  a  very  solid  texture. 
When  bloodvessels  are  traced  into  an  abscess  of  the 
lungs,  I  have  found  them,  upon  examination,  very 
much  contracted,  just  before  they  reach  the  abscess, 
so  that  the  opening  of  their  extremities  has  been  clo- 
sed up  entirely.  On  such  occasions  it  will  require  a 
probe  to  be  pushed  with  a  good  deal  of  force,  in  or- 
der to  open  again  their  extremities.  In  these  con- 
tracted vessels  the  blood  is  coagulated,  as  it  is  under 
similar  circumstances  in  other  parts  of  the  bodv.* 
This  change  in  the  blood  vessels  is,  no  doubt,  with 
a  view  to  prevent  large  haemorrhages  from  taking 
place,  which  would  certainly  be  almost  immediately 
fatal. 


Tubercles. 

There  is  no  morbid  appearance  so  common  in  the 
lungs  as  that  of  tubercles.  These  consist  of  rounded 
firm  white  bodies,  interspersed  through  their  sub- 
stance. They  are  probably  formed  in  the  cellular 
structure,  which  connects  the  air  cells  of  the  lungs 
together,  and  are  not  a  morbid  affection  of  glands,  as 
has  been  frequently  imagined.  There  is  no  glandu- 
lar structure  in  the  cellular  connecting  membrane  of 
the  lungs  ;  and  on  the  inside  of  the  branches  of  the 
trachea,  where  there  are  follicles,  tubercles  have  nev- 
er been  seen.     They  are  at  first  very  small,  being  not 

■  Sec  Dr.  Stavk's  works,  p.  $8. 

G 


[     SO     J 

larger  than  the  heads  of  very  small  pins,  and  in  this* 
ease  are   frequently  accumulated  in   small   clusters. 
The  smaller  tubercles  of  a  cluster  probably    grow  to- 
gether and  form  one  larger  tubercle.     The   most  or- 
dinary size  of  tubercles  is  about  that  of  a  garden  pea, 
but  they  are  subject  in  this  respect  to  much  variety. 
They    adhere  pretty  closely  to  the  substance  of  the 
lungs,  have  no  peculiar  covering  or  capsule,  and  have 
little  or  no  vascularity.     When  cut   into,  they   are 
found  to  consist  of  a  white,  smooth  substanfce,  having 
a  firm  texture,  and  often  contain  in  part  a  thick  curd.ly 
pas.    When  a  tubercle  is  almost  entirely  changed  into 
pus,  it  appears  like  a  white  capsule,  in  which  the  pus 
is  lodged.     When  several  tubercles  of  considerable 
size  are   grown    together,  so   as  to  form   a   pretty 
large  tuberculated  mass,  pus  is  very  generally  found 
upon  cutting  into  it.     The  pus  is  frequently  thick  and 
curdly  ;  but  when  in  considerable  quantity,  it  is  thin- 
ner, and  resembles  very  much  the  pus  from  a  com- 
mon sore.     In  cutting  into  the  substance  of  the  lungs, 
a  number   of  abscesses   is   sometimes  found,  from 
pretty  large  tubercles  having  advanced  to  a  state  of 
suppuration.     In  the  interstices  between  these  tuber- 
cles, the  lungs  are  frequently  of  a  harder,  firmer  tex- 
ture, with  the  cells  in  a  great   measure  obliterated. 
The  texture  of  the  lungs  on  many  occasions,  howev- 
er, round  the  boundaries  of  an  abscess,  is  perfectly 
natural. 

I  have  sometimes  seen  a  number  of  small  abscess- 
es interspersed  through  the  lungs,  each  of  which  was 
not  larger  than  a  pea.  The  pus  in  these  is  rather 
thicker  than  what  arises  from  common  inflammation, 
and  resembles  scrofulous  pus.  It  is  probable  that 
these  abscesses  have  been  produced  by  a  number  of 
small  scattered  tubercles  taking  on  the  process  of  sup- 
puration. The  lungs  immediately  surrounding  these 
abscesses  are  often  of  a  perfectly  healthy  structure, 
none  of  the  cells  being  closed  up  by  adhesions. 

When  tubercles  are  converted  into  abscesses, 
pthibis  pulmonalis  is  produced,  one  of  the  most  des- 
tructive diseases  in  this  island.     Tubercles  are  some- 


r  si  ] 

■times  found  in  the  lungs  of  children  at  a  very  early  age, 
viz.  two  or  three  years  old  ;  but  they  most  frequent- 
ly occur  shortly  before  the  completion  of  the  growth. 
They  are  apt,  likewise,  to  be  formed  at  rather  an  ad- 
vanced age. 

In  cutting  into  the  lungs,  a  considerable  portion  of 
their  structure  sometimes  appears  to  be  changed  into 
a  whitish  soft  matter,  somewhat  intermediate  between 
a  solid  and  a  fluid,  like  a  scrofulous  gland  just  begin- 
ning to  suppurate.  This  appearance  I  believe  is  pro- 
duced by  scrofulous  matter  being  deposited  in  the 
cellular  substance  of  a  certain  portion  of  the  lungs, 
and  advancing  towards  suppuration.  It  seems  to  be 
the  same  matter  with  that  of  the  tubercle,  but  only 
diffused  uniformly  over  a  considerable  portion  of  tlie 
•lungs,  while  the  tubercle  is  circumscribed. 


Soft  pulpy  Tubercle. 

\  have  seen  another  sort  of  tubercle  in  the  lungs, 
which  I  believe  to  be  very  rare.  It  consists  of  a  soft 
tumour,  formed  of  a  light  brown,  smooth  substance. 
This  is  not  contained  in  any  proper  capsule,  but  ad- 
heres immediately  to  the  common  structure  of  the 
lungs.  In  cutting  through  several  of  these  tumours 
I  did  not  find  any  of  them  in  a  state  of  suppuration. 
They  were  commonly  as  large  as  a  goosberry,  and 
were  chiefly  placed  upon  the  surface  of  the  lungs  ; 
some,  however,  w7ere  scattered  through  their  sub- 
stance, of  a  smaller  size.  These  are  very  different 
in  their  appearance  from  the  common  tubercle  last 
•described. 


JVater  accumulated  in  the  substance  of  the  lungs. 

The  structure  of  thelungs  may  be  said  to  consist 
of  air  cells,  and  the  common  cellular  membrane  of  the 
body.     In  this   cellular  membrane  there  is  always 


[     52     ] 

some  moisture,  "which  is  necessary  for  the  easy  mo- 
tion of  one  part  of  the  lungs  upon  another  in  their 
contraction  and  dilatation.  There  is  a  considerable 
difference  in  the  quantity  of  this  moisture  in  different 
persons,  as  may  be  seen  by  cutting  into  the  substance 
of  the  lungs  ;  for  under  such  circumstances  there  will 
always  ooze  out  from  the  cut  surface  more  or  less  of 
an  aqueous  fluid  mixed  with  globules  of  air.  Some- 
times, however,  the  quantity  is  so  large  that  it 
amounts  to  a  disease,  forming  what  may  be  called  an- 
asarca of  the  lungs.  It  has  not  occurred  to  me  to  see 
any  well  marked  example  of  this  disease,  but  it  has 
been  observed  by  others.*  It  is  hardly  necessary  to 
mention,  that  in  proportion  to  the  accumulation  of  the 
water  the  air  ceils  must  be  necessarily  compressed,  so 
that  a  sufficient  quantity  of  air  cannot  be  admitted  in- 
to the  lungs  for  producing  the  due  degree  of  influence 
noon  the  blood. 


Lungs  distended  xvlth  Air. 

In  opening  into  the  chest,  it  is  not  unusual,  to  find 
that  the  lungs  do  not  collapse,  but  that  they  fill  up  the 
cavity  completely  on  each  side  of  the  heart.  When 
examined,  their  cells  appear  full  of  air,  so  that  a  pro- 
digious number  of  small  white  vesicles  are  seen  upon 
the  surface  of  the  lungs  immediately  under  the  pleura. 
The  branches  of  the  trachea  are  often  at  the  same 
time  a  irood  deal  filled  with  a  mucous  fluid. 


Air  Cells  of  the  Lungs  enlarged. 

The  Iuijgs  are  sometimes,  although  I  believe  very 
rarely,  formed  into  pretty  large  cells,  so  as  to  resem- 
ble somewhat  the  lungs  of  an  amphibious  animal. 
Of  this  I  have   now   seen  three  instances.     The  en- 

*  Sec  Dr.  Soeinmcrving's  Geiman  Translaiicn  of  the  Morbid  Aratcmj-, 
p-  45. 


[     53     ] 

largement  of  the  cells  cannot  well  be  supposed  to  arise 
from  any  other  cause,  than  the  air  being  not  allowed 
the  common  free  egress  from  the  lungs,  and  therefore 
accumulating  in  them.  It  is  not  improbable  also,  that 
this  accumulation  may  sometimes  break  down  two  or 
thrce  contiguous  cells  into  one,  and  thereby  form  a 
cell  of  a  very  large  size. 

Air  Vesicles  attached  to  the  Edge  of  the  Lungs. 

Vesicles  containing  air  have  occasionally  been  seen 
attached  to  the  edge  of  the  lungs.  They  do  not  com- 
municate, however,  with  the  structure  of  this  organ, 
but  arc  complete  in  themselves.  Upon  the  first  view, 
it  might  be  thought  probable  that  they  were  merely 
some  of  the  air  cells  enlarged ;  but  as  they  do  not 
communicate  with  any  of  the  air  cells,  this  opinion  is 
not  well  founded.  It  is  most  likely  that  they  are  a 
morbid  structure,  formed  in  the  same  manner  as  the 
air  vesicles  attached  to  the  intestines  and  mesentery  of 
some  quadrupeds,  and  that  the  very  minute  blood 
vessels  which  ramify  upon  the  vesicles,  have  the  pow- 
er of  secreting  the  air.* 


Lungs  changed  into  a  substance  like  Liver. 

The  lungs  are  sometimes  converted  into  a  solid  sub- 
stance very  much  resembling  the  liver.  It  has  near- 
ly the  same  solidity,  and  the  same  general  appearance. 
I  have  only  seen  an  example  of  this  change  in  a  pre- 
paration, and  I  am  inclined  to  believe  that  it  had  been 
produced  by  a  wide  extended  inflammation,  in  which  a 
large  quantity  of  coagulable  lymph  had  been,  extrava- 
sated  into  the  substance  of  the  lungs.  The  extrava- 
sation would  necessarily  render  the  texture  of  the 
lungs  very  solid  ;  and  the  history  of  the  symptoms 
which  have  been  observed  to  attend  similar  morbid 

*  Sec  Hunter's  Animal  Economy,  p  165. 


I     54     ] 

changes,  supports  this  opinion.  The  symptoms  are 
■those  which  are  produced  by  an  inflammation  of  the 
lungs. 


Lungs  converted  into  Bone. 

Part  of  the  lungs  is  occasionally  converted  into 
bony  substance  ;  but  this  is  a  very  rare  disease.  The 
small  vessels  ramifying  through  the  substance  of  the 
lungs  under  such  circumstances  separate  bony  matter 
from  the  blood.  In  the  only  instance  which  I  have 
known  of  this  complaint,  the  process  would  appear 
to  have  been  rapid.  There  was  great  difficulty  of 
breathing  before  the  person  died,  but  this  difficulty 
had  been  only  for  a  very  few  weeks.  Each  of  the 
lungs  was  undergoing  the  same  change  of  structure 
which  had  made  considerable  progress.  In  the  par- 
ticular case  to  which  1  allude,  there  had  been  a  very 
strong  disposition  to  form  bone  in  the  constitution. 
A  very  large  bony  tumour  had  been  formed  round 
one  of  the  knees  of  this  person  ;  and  very  soon  after 
the  knee  and  leg  were  removed  by  amputation,  the 
difficulty  of  breathing  began,  which  was  occasioned  by 
a  part  of  the  lungs  being  converted  into  bone.  In  this 
case  there  was  a  transference  of  the  disease  from  an 
external  to  an  internal  part,  similar  to  the  translation 
of  gout  or  rheumatism. 


A  solid  Tumour  compressing  the  Lungs. 

-  I  have  also  seen  a  tumour  as  large  as  an  orange,  at- 
tached to  the  lungs  on  one  side  by  a  loose  membran- 
ous connection  and  in  some  degree  compressing  them  ; 
this  tumour  consisted  of  a  porous  substance,  which 
resembled  neither  the  structure  of  what  is  commonly 
understood  to  be  a  scirrhous  nor  that  of  a  scrofulous 
tumour,  but  had  an  appearance  somewhat  peculiar  to 
itself. 


t     55     J 


Earthy  Concretions  in  the  Lungs. 

Earth)r  concretions  have  occasionally  been  found  irr. 
the  lungs,  although  it  is  a  rare  appearance  of  disease. 
These  arc  often  small,  but  sometimes  form  masses  of 
a  considerable  size.*  Even  a  considerable  portion 
of  the  lungs  lias  been  known  to  be  changed  into  au 
earthy  substance. :{: 

Hydatids. 

Hydatids  arc  also  sometimes  formed  in  the  lungs, 
and  are  many  of  them  brought  up  by  coughing.  They 
are  of  the  same  sort  with  the  hydatids  formed  in  the 
liver,  the  nature  of  which  we  shall  endeavour  to  ex- 
plain afterwards. 


SYMPTOMS. 

In  inflammation  of  the  substance  of  the  lungs,  the 
symptoms  correspond  a  good  deal  with  those  of  pleuri- . 
sy.  Indeed  inflammation  of  the  lungs  is  almost  con- 
stantly attended  with  inflammation  of  thepleura,  so  that 
it  is  diflicult  to  discriminate  between  them  in  practice. 
But  it  is  of  little  consequence  to  be  able  to  do  this,  as 
the  means  of  cure  are  the  same  in  both  diseases. 
When  the  inflammation  of  the  lungs  is  pure,  the  pleura 
being  not  affected,  the  pain  in  the  chest  has  been  ob- 
served to  be  more  obtuse  than  in  pleurisy,  and  the  pulse 
to  be  less  hard.  The  respiration  is  very  diflicult, 
and  the-veins  of  the  neck  are  sometimes  observed  to 
be  distended  with  blood,  the  face  to  be  tumid,  and 
there  is  a  purplish  hue  of  the  lips  and  cheeks.     These 

•  VIA.  Morgagni,  Epitt,  XVII.  Art.  19.  XV.  Art.  2J. 
\  Via.  Morgagni,  Ep  st.  XXII-  Aft.  R, 


[     56     ] 

effects  arisefromthe  venal  blood  being  transmitted  with 
difficulty  through  the  inflamed  lungs.  This  is  occasion- 
ed by  an  extravasation  of  the  coagulable  lymph  into  a 
considerable  part  of  their  substance,  which  both  pre- 
vents the  lungs  from  sufficiently  expanding  them- 
selves, and  compresses  many  air  cells,  so  that  the  prop- 
er quantity  of  air  is  not  admitted  into  the  lungs  for 
producing  the  full  change  of  colour  upon  the  blood. 

When  inflammation  of  the  lungs  terminates  in 
suppuration,  it  may  be  known  by  rigors,  by  a  dimin- 
ution of  the  pain  in  the  chest,  and  by  an  expectora- 
tion of  pus. 


When  tubercles  are  forming  in  the  lungs,  but  have 
not  advanced  to  suppuration,  they  are  attended  with 
a  slight  cough,  with  occasional  difficulty  of  breathing, 
and  a  pulse  somewhat  accelerated.  These  are  symp- 
toms which  commonly  usher  in  phthisis  pulxnonalis, 
aad  are  frequently  overlooked,  both  by  the  patients 
themselves  and  their  friends.  When  the  tubercles 
have  begun  to  suppurate,  and  abscesses  to  be  formed, 
then  there  is  an  expectoration  of  a  thick  pus,  which 
is  occasionally  tinged  with  blood,  emaciation,  debili- 
ty, and  that  peculiar  affection  of  the  system  which  is 
known  by  the  name  of  hectic  fever. 


The  symptoms  attending  the  large  brown  tubercle 
are  unknown  to  me. 


When  the  cells  of  the  lungs  are  much  enlarged  in 
their  size,  persons  have  been  remarked  to  be  long 
subject  to  difficulty  of  breathing  ;  but  I  believe  no 
symptom  is  at  present  known,  by  which  this  disease 
may  be  discriminated  from  some  others  incident  to 
the  chest. 


[     57     ] 


In  some  cases  in  which  the  lungs  have  been  conver- 
ted into  a  substance  like  the  liver,  symptoms  have 
been  observed  similar  to  those  which  attend  inflam- 
mation of  the  lungs.  I  am  inclined  to  believe  that 
this  appearance  of  the  lungs  is  produced  by  an  ex- 
tensive extravasation  of  coagulable  lymph  into  their 
substance,  during  an  attack  of  inflammation. 


When  earthy  concretions  are  formed  in  the  lungs, 
persons  are  more  or  less  subject  to  difficulty  of  breath- 
ing, and  a  cough.  Occasionally  some  of  these  con- 
cretions are  coughed  up,  which  circumstance  becomes 
the  discriminating  mark  of  this  disease.  Without  it, 
this  disease  could  not  be  distinguished  from  several 
others  which  attack  the  chest. 


When  hydatids  are  formed  in  the  lungs,  they  pro- 
duce a  cough,  difficulty  of  breathing,  and  some  fre- 
quency of  the  pulse.  They  are  occasionally  forced 
op  by  a  violent  fit  of  coughing  ;  and  this  circumstance 
only  can  discriminate  the  disease  in  the  living  body. 

H 


[     SB     J 


CHAP.  V, 


DISEASED  APPEARANCES  OF  THE  THYROID  GLAND, 
THE  LARYNX,  AND  THE  PARTS  CONTAINED  IH 
THE  POSTERIOR  MEDIASTINUM. 


B 


_>EFORE  we  describe  the  diseased  appearances 
of  the  parts  which  are  contained  in  the  posterior  me- 
diastinum, we  shall  take  notice  of  the  morbid  changes 
to  which  the  thyroid  gland  and  the  larynx  are  liable. 
These  are  so  closely  connected  with  the  trachea,  thai 
a  description  of  their  morbid  changes  could  not  be  in- 
troduced so  properly  in  any  other  place. 

Inflammation  of  the  Thyroid  Gland. 

The  thyroid  gland  is  sometimes  attacked  with 
common  inflammation,  but  this  happens  rarely. 
There  are  no  peculiar  causes  acting  upon- it  to  pro- 
duce inflammation,  and  it  would  seem  to  be  as  little 
liable  to  be  excited  to  this  diseased  action  as  any 
gland  in  the  body.  When  the  thyroid  gland  is  inflam- 
ed, it  exhibits  the  common  appearances  which  take 
place  in  the  inflammation  of  the  substance  of  other 
parts.  Its  blood  vessels  are  enlarged  in  their  size, 
and  the  number  of  branches  which  are  capable  of  con- 
taining the  red  globules  of  blood  is  increased.  Hence 
it  appears  much  more  vascular  than  in  a  natural  state. 
It  is  increased  in  its  bulk,  and  feels  considerably 
firmer  to  the  touch  than  when  healthv  ;  and  these  ef- 
fects  are  produced  partly  by  the  increased  quantity  ofi 


[     59     3 

blood  which  is  circulating  through  it,  and  partly  by 
the  extravasation  of  coagulable  lymph,  and  perhaps 
of  blood,  into  its  substance. 


Bronchocele. 

The  morbid  change  of  structure  to  which  the  thy- 
xoid  gland  is  most  liable,  is  that  swelling  of  it  called 
bronchocele.  This  is  apt  to  take  place  in  different 
individuals  of  the  same  family,  and  women  are  more 
liable  to  be  affected  with  it  than  men.  It  is  more  prev- 
alent in  some  districts  of  countries  than  in  others,  and 
those  where  it  is  most  prevalent  are  mountainous. 

The  swelling  of  the  thyroid  gland  in  bronchocele 
often  increases  to  a  very  large  size,  and  sometimes 
grows  irregularly,  forming  projecting  tumours  upon 
the  anterior  part  of  the  neck.  This  irregularity  of 
growth  is  mere  common  in  that  part  of  Savoy,  where 
the  disease  is  endemial,  than  in  Great  Britain. 

When  a  section  is  made  of  the  thyroid  gland  affect- 
ed with  this  disease,  it  is  found  to  consist  of  a  num- 
ber of  cells  which  contain  a  transparent  viscid  fluid. 
These  cells  vary  in  their  size  in  different  parts  of  the 
same  gland,  and  in  different  swellings  of  the  same 
kind  in  different  individuals.  Some  of  them  are  so 
large  as  to  be  able  to  contain  ?i  small  pea,  but  most 
of  them  are  of  a  smaller  size.  The  viscid  fluid,  when 
the  gland  has  been  preserved  for  some  time  in  spirits, 
is  changed  into  a  transparent  jelly.  From  this  account 
of  the  morbid  change  of  structure  which  takes  place 
in  bronchocele,  it  seems  not  unreasonable  to  suppose 
that  the  swelling  depends  upon  a  vitiated  and  increas- 
ed secretion  in  the  gland.  The  secretion  being  in 
large  quantity,  gradually  distends  the  cells,  increasing 
thereby  their  capacity,  and  this  enlargement  of  the 
cells  forms  the  general  swelling  of  the  gland.  What 
is  now  said,  however,  is  thrown  out  merely  as  a  con- 
jecture, and  should  be  received  with  caution. 


[     GO     ] 


Scirrhous  of  the  Thyroid  Gland. 

The  thyroid  gland  sometimes  becomes  scirrhous, 
but  is  not  so  liable  to  this  disease  as  some  other  glands 
of  the  body.  When  it  is  affected  by  this  disease,  it 
becomes  enlarged  in  its  size,  but  not  to  any  consid- 
erable degree,  and  is  hard  to  the  feeling.  When  a 
section  is  made  of  it,  it  is  found  to  consist  of  a  solid 
substance,  with  very  little  of  that  cellular  structure 
which  is  so  strongly  marked  in  bronchocele. 

This  gland  is  apt  to  become  swelled  and  hard  when 
ulcers  are  formed  at  the  upper  end  of  the  oesophagus. 
This  effect  is  sometimes  produced  by  the  ulcer  of  the 
oesophagus  spreading  to  the  thyroid  gland.  The 
same  change,  however,  has  been  observed  to  take 
place  where  the  ulcer  had  not  reached  so  far,  and 
where  the  gland  was  entire.  This  might  lead  to  the 
opinion,  that  some  ducts  of  communication  exist  be- 
tween the  thyroid  gland  and  the  upper  part  of  the 
oesophagus.  These  ducts  have  been  supposed  by 
several  anatomists,  but  their  existence  has  never  yet 
been  demonstrated. 


The  Thyroid  Gland  converted  into  Bone. 

The  thyroid  gland,  or  a  part  of  it,  is  occasionally 
changed  in  old  people  into  a  bony  mass,  but  this  dis- 
ease is  of  rare  occurrence.  It  is  commonly,  I  believe, 
a  disease  of  no  consequence  ;  but  it  is  reasonable  to 
think,  that  the  bony  mass  by  an  irregular  growth 
might  in  some  instances  so  irritate  the  larynx,  or 
the  upper  part  of  the  trachea,  as  to  produce  inflam- 
mation and  ulceration  of  these  parts,  and  to  prove  ul- 
timately fatal. 


C    "    ] 


Larynx — The  Cartilages  of  the  Larynx   converted 
into  Bone. 

The  cartilages  of  the  larynx  sometimes  become  bo- 
ny, either  at  the  middle  or  a  more  advanced  period  of 
life.  When  the  disposition  to  form  bony  matter  in 
the  larynx  is  not  very  strong,  portions  of  the  thyroid 
cartilage  only  are  converted  into  bone  ;  but  when  the 
disposition  is  powerful,  then  all  the  cartilages  are 
changed  into  a  bony  substance.  When  this  is  the 
case  they  become  liable  to  any  changes  which  might 
take  place  in  ordinary  bone.  Accordingly,  some  of 
these  cartilages  so  changed  into  bone  have  been  known 
to  exfoliate,  and  to  be  thrown  out  by  a  violent  fit  of 
coughing  or  vomiting.  Dr.  Hunter  had  an  opportu- 
nity of  knowing  an  instance  Avhere  the  cricoid  carti- 
lage, being  converted  into  bone,  was  separated  by 
exfoliation,  and  afterwards  coughed  up.  It  is  not  to 
be  understood  from  what  has  been  said,  that  the  car- 
tilages of  the  larynx,  when  changed  into  bone,  are 
more  liable  to  become  dead  and  exfoliate  than  the 
common  bones  of  the  body.  The  instances  in  which 
they  have  been  known  to  exfoliate  are,  I  believe,  ex- 
tremely rare. 

Ulcers  in  the  cavity  of  the  Larynx. 

The  inner  membrane  of  the  larynx  is  very  apt  to 
be  inflamed,  and  this  generally  accompanies  the  in- 
flammation of  the  inner  membrane  of  the  trachea, 
as  we  shall  have  occasion  to  mention  afterwards. 
Sometimes,  however,  an  inflammation  shall  take 
place  which  is  confined  to  the  cavity  of  the  larynx, 
and  it  shall  occasionally  advance  to  suppuration*. 
Of  this  I  have  known  several  instances.  Suppura- 
tion is  most  apt  to  take  place  in  the  sacculi  h- 
ryngis :    and  the  ulcers  which   I  have  seen  there  arc 


[     62     ] 

sometimes    attended  with  a   scrofulous  thickening 
of  the  surrounding  parts. 

Diseased  Appearances  of  the  Parts  contained  in  the 
Posterior  Mediastinum. 

By  the  posterior  mediastinum,  is  meant  that  space 
which  lies  between  the  laminse  of  the  pleura,  that 
pass  from  the  root  of  the  lungs  to  each  side  of  the 
spine.  The  space  is  of  considerable  size,  and  con- 
tains a  portion  of  the  trachea  arteria,  of  the  oesopha- 
gus, of  the  thoracic  duct,  of  the  descending  aorta, 
and  the  vena  azygos,  besides  seme  absorbent  glands. 


Diseased  Appearances  of  the  Trachea. 

The  inner  membrane  of  the  trachea  is  not  uncom- 
monly inflamed  to  a  greater  or  less  degree.  In  this 
state  it  is  crowded  with  minute  florid  vessels,  which 
give  it  a  general  appearance  of  vascularity.  When 
there  is  no  inflammation,  it  appears  in  the  dead  body 
a  white  pulpy  membrane,  and  there  are  rarely  to  be 
seen  any  red  vessels  ramifying  in  it.  While  the  in- 
ner membrane  is  inflamed,  the  secretion  from  its 
glands  is  very  much  increased,  and  therefore  its  cav- 
ity is  found,  a  good  deal  filled  with  a  mucous  fluid  ; 
even  pus  is  sometimes  formed,  and  both  fluids  are 
mixed  with  globules  of  air.  This  is  the  state  of  the 
trachea  in  a  very  violent  catarrh,  and  also  in  some 
cases  where  there  are  scrofulous  abscesses  of  the 
lunp;s  attended  with  hoarseness,  and  a  sense  of  sore- 
ness  along  the  trachea  :  the  same  appearances  are  al- 
so observable  in  the  inner  membrane  of  the  larynx. 


Appearances  of  the    Trachea  hi  the  Croup. 

When  the  inner  membrane  of  the  trachea  is  in- 
flamed, it  is  sometimes  lined  with  a  layer  of  a  yellow- 


L     63     } 

ish  pulpy  matter.  This  does  not  adhere  firmly  to  the 
inner  membrane,  but  may  be  easily  separated.  It 
extends  from  the  upper  part  of  the  cavity  of  the  la- 
rynx, into  the  small  branches  of  the  trachea,  which 
are  distributed  through  the  substance  of  the  lungs. 
There  is  at  the  same  time  a  goo*!  dm\  of  mucus  in  the 
trachea  and  its  branches,  together  with  a  mixture  of 
pus.  This  is  the  appearance  of  the  inside  of  the 
trachea,  in  patients  who  have  died  from  the  croup. 


Polypus, 

The  trachea  and  its  branches  are  sometimes  lined 
with  a  layer  of  a  yellowish  or  whitish  matter,  forming 
a  sort  of  tube,  which  is  applied  to  the  inner  surface 
loosely.  It  has  not  occurred  to  me  to  see  any  instance 
of  it  in  the  dead  bodies  which  I  have  examined  ;  but 
I  havq  seen  several  examples  of  it  in  preparations. 
The  inner  membrane  of  the  trachea  seems  to  be  per- 
fectly natural,  and  the  layer  of  adventitious  membrane 
resembles  exactly  the  coagulable  lymph  which  is 
thrown  out  in  other  parts  of  the  body  ;  I  have  there- 
fore no  doubt  of  its  being  that  substance.  Since  this 
disease  (which  is  called  polypus)  lasts  for  a  long 
time,  and  is  not  attended  with  symptoms  of  inflam- 
mation, it  appears  probable  that  the  vessels  of  the  in- 
ner membrane  of  the  trachea  possess  a  power  of  sep- 
arating the  coagalable  lymph  from  the  blood,  and  that 
this  disease  consists  in  a  peculiar  action  of  these  ves- 
sels. 

The  trachea  is  sometimes  filled  with  a  solid  sub- 
stance, of  the  same  kind  with  what  we  have  described. 
Of  this  I  have  only  seen  one  instance,  and  it  occurs,  I 
believe,  much  more  rarely  than  the  other. 

The  tubular  substances  which  arc  thrown  out  from 
the  trachea  in  coughing,  and  which  constitute  the 
most  ordinary  form  of  polypus,  were  considered  for- 
merly, by  some  anatomists  of  distinguished  reputa- 
tion, as  blood  vessels.     It  is  singular  that  they  should 


[     64     ] 

have  paid  so  little  attention  to  the  appearance  of  these 
tubular  substances  as  to  have  mistaken  them  for  blood 
vessels  ;  and  it  is  still  more  singular,  that  it  should 
never  have  occurred  to  their  reflection,  that  blood 
vessels  of  such  a  size  could  not  be  coughed  up,  with- 
out a  very  large  quantity  of  blood  passing  along  with 
them. 

A  more  modern  opinion  about  the  nature  of  these 
tubular  substances  has  been  that  they  consist  of  dried 
mucus.  This,  although  more  plausible  than  the  for- 
mer, is  equally  ill  founded.  The  mucus  which  is 
secreted  by  the  inner  membrane  of  the  trachea,  is  ex- 
actly of  the  same  kind  with  that  secreted  by  the  inner 
membrane  of  the%  nose.  Every  person  is  acquainted 
with  the  appearance  of  the  mucus  of  the  nose  when 
dried.  The  mucus  of  the  trachea,  when  dried  would 
have  the  same  appearance.  The  tubular  substances 
coughed  up  in  polypus  of  the  trachea,  present  an  ap- 
pearance to  the  eye  very  different,  and  (as  has  been 
already  noticed)  look  exactly  like  the  coagulable 
lymph.  The  influence  of  the  air  in  drying  the  mucus 
would  seem  to  extend  but  a  little  way  from  the  exter- 
nal surface  of  the  body,  for  the  mucus  is  fluid  even 
in  the  posterior  nostrils. 


Trachea  scirrhous. 

The  trachea  I  have  seen  narrowed  in  diameter  for 
two  or  three  inches,  thickened  in  its  substance,  and 
the  inner  membrane  has  been  raised  into  a  number  of 
little  hard  tubercles.  This  state  of  the  trachea  was 
accompanied  with  a  scirrhous  affection  of  some  absor- 
bent glands,  which  closely  adhered  to  it ;  and  it  appear- 
ed to  me  that  the  disease  in  the  glands  had  spread  so 
as  to  affect  the  trachea. 


C     65     ] 


Rings  of  the  Trachea  ossified* 

The  cartilaginous  rings  of  the  Trachea  occasionally 
become  ossified.  When  the  ossification  is  inconsid- 
erable, the  function  of  the  trachea  will  hardly  be  af- 
fected by  it ;  but  where  the  rings  are  entirely  ossifi- 
ed, the  flexibility  of  the  trachea  must  be  much  les- 
sened, and  its  cavity  will  not  admit  of  being  so  much 
contracted  as  in  the  healthy  state,  by  the  action' of  the 
muscular  fibres,  which  form  a  part  of  its  structure. 
In  consequence  cf  this  the  mucus  which  is  occasion- 
ally accumulated  will  not  be  so  readily  expelled  by 
coughing,  and  probably  the  air  will  not  be  thrown  out 
in  so  small  a  column,  nor  with  so  much  momentum. 


Ulcers  of  the  Trachea. 

The  trachea  is  doubtless  liable  to  be  destroyed  in 
part  by  ulceration,  from  causes  acting  immediately 
upon  itself;  but  in  the  instances  which  I  have  seen, 
the  ulceration  has  been  connected  with  ulceration  of 
the  oesophagus.  As  the  oesophagus  is  more  liable  to 
this  disease,  it  is  probable  that  in  such  cases  the  ul- 
ceration has  begun  in  the  oesophagus,  and  spread  to 
the  trachea. 


Diseased  Appearances  of  the  (Esophagus. 

The  oesophagus  is  frequently  lined  with  a  layer  of 
the  coagulable  lymph,  which  is  continued  from  the 
cavity  of  the  mouth. 

This,  it  is  said,  sometimes  extends  over  the  whole 
intenstinal  canal  ;  but  I  believe  this  appearance  to  be 
extremely  rare,  and  it  commonly  terminates  at  the 
lower  end  of  the  oesophagus.  The  inner  membrane  of 

I 


[     66     J 

the  month  is  much  more  vascular  than  in  its  natu- 
ral state,  shewing  a  deep  red  colour  ;  but  in  exam- 
inations after  death  the  appearance  of  greater  redness 
is  sometimes  scarcely  observable  in  the  oesophagus. 
This  disease  is  known  under  the  name  of  aphtha^ 
and  is  much  more  often  to  be  observed  in  the  living 
than  the  dead  body, 


Spasmodic  stricture  of  the  (Esophagus. 

The  oesophagus  is  liable  to  stricture,  produced  by 
the  contraction  of  its  muscular  fibres  at  some  particu- 
lar part.  This  disease  is  most  common  in  women 
'whose  constitutions  are  delicate,  and  much  subject  to 
nervous  influence.  When  such  a  disease  is  examined 
in  the  dead  body,  the  oesophagus  is  found  to  be  more 
•r  less  contracted  in  some  part  of  it,  and  it  feels  hard- 
er than  usual,  as  happens  to  all  muscles  in  a  contract- 
ed state.  There  is  no  appearance  of  diseased  struc- 
ture usually  combined  with  it.  I  can  suppose,  how- 
ever, that  this  contraction  might  lay  the  foundation  of 
a  permanent,  and  even  a  fatal  disease.  The  muscu- 
lar fibres  of  the  oesophagus  might  so  press  on  the  in- 
ner membrane,  as  to  excite  inflammation  in  it,  which 
might  advance  to  suppuration,  and  would  most  prob- 
ably terminate  fatally. 


Stricture  from  the  puckering  of  the  inner  Membr  me 
of  the  (Esophagus. 

I  once  saw  a  very  unusual  stricture  of  the  oesopha- 
gus. It  consisted  in  its  inner  membrane  being  puck- 
ered together,  so  as  to  form  a  narrowness  of  the  canal 
at  a  particular  part,  which  would  hardly  allow  a  com- 
mon garden  pea  to  pass.  There  was  no  appearance, 
however,  of  diseased  structure  in  the  inner  membrane 
which  was  so  contracted,  and  the  muscular  part  of 
the  oesophagus  surrounding  it  was  perfectly  sound.  I 


C     67     ] 

know  that  this  disease  was  very  slow  in  its  progress, 
for  the  person  in  whom  it  took  place  had  been  for  ma- 
ny years  affected  with  a  difficulty  of  swallowing,  and 
could  only  swallow  substances  of  an  extremely  small 
size. 


Stricture  attended  with  Ulcer, 

The  most  common  appearance  of  disease  in  the  oe- 
sophagus, is  that  of  an  ulcer  in  its  cavity.  Ulcers  of 
the  oesophagus  are  sometimes  of  a  common  nature, 
but  most  frequently  they  are  attended  with  a  scir- 
rhous affection.  When  they  arise  from  common  in- 
flammation, the  structure  of  the  oesophagus  immedi- 
ately surrounding  the  ulcer  is  but  little  thickened, 
and  there  is  the  appearance  of  the  usual  erosion  in  ul- 
cers. When  the  ulcer  is  of  a  scirrhous  nature  the 
oesophagus  in  the  neighbourhood  is  very  much  thick- 
ened, and  is  very  hard  in  its  texture.  When  this 
texture  is  examined,  it  either  consists  of  a  hard,  uni- 
formly fleshy  substance,  or  this  is  a  little  intersected 
by  membranes,  or  it  is  gristly.  Under  such  circum- 
stances the  canal  of  the  oesophagus  is  always  more  or 
less  narrowed,  and  in  some  cases  is  almost  wholly  ob- 
literated. It  is  worthy  of  remark,  that  these  ulcers 
happen  most  frequently,  either  immediately  under  the 
pharynx,  or  near  the  cardia. 

Any  substance  capable  of  irritating  the  inner  mem- 
brane of  the  oesophagus,  by  having  sharp  hard  pro- 
jections, will  doubtless  be  more  likely  to  affect  the 
oesophagus,  where  it  first  enters  into  it.  In  an  oe- 
sophagus, therefore,  predisposed  to  scirrhous,  such 
an  accident  may  prove  an  exciting  cause,  and  the  dis- 
ease will  more  frequently  take  place  at  its  upper  end. 
At  the  cardia  too,  there  is  a  peculiar  arrangement  of 
the  muscular  fibres,  which  are  capable  of  acting  in 
some  degree  like  a  sphincter,  and  which  probably  pro- 
duce on  many  occasions  a  narrowness  of  the  canal 
there.     This  will  render  the  oesophagus  at  the  cardia 


[     68     ] 

more  liable  to  be  injured  by  the  passage  of  any  hard 
substance,  and  may  ultimately  lay  the  foundation  of  a 
scirrhous  ulcer.  This  is  the  account  which  the  late 
Dr.  Hunter  used  to  give  of  the  frequent  situation  of 
ulcers  at  the  upper  and  lower  extremities  of  the  oe- 
sophagus, and  it  seems  to  have  great  weight  It 
happens,  however,  most  commonly  that  ulcers  of  the 
oesophagus  arise  spontaneously,  or  in  other  words, 
from  causes  within  itself  which  we  cannot  ascertain. 
"When  an  ulcer  takes  place  at  the  upper  end  of  the  oe- 
sophagus, it  is  apt  to  spread  into  the  substance  of  the 
thyroid  gland.  In  this  case  the  gland  becomes  hard, 
enlarged,  and  ulcerated  :  but  in  some  instances  it  has 
been  known  to  enlarge,  where  the  ulcer  of  the  oesoph- 
agus had  not  spread  so  far  as  to  reach  it. 


(Esophagus  cartilaginous. 

A  portion  of  the  oesophagus  has  been  observed  by* 
some  anatomists  to  be  converted  into  cartilage,  and  to 
have  its  diameter  at  that  part  very  much  diminished 
in  size.*  This  was  probably  only  a  strong  example 
of  the  gristly  texture  above  described. 

Fungus  in  the  Pharynx. 

I  have  seen  an  instance  of  a  fungus  arising  on  the 
inside  of  the  pharynx  and  the  upper  end  of  the  oesoph- 
agus, which  is  to  be  considered  as  a  rare  disease. 
When  cut  into  it  appeared  to  have  a  fibrous  structure, 
disposed  in  some  measure  at  right  angles  to  the  inner 
membrane  upon  which  it  was  formed,  and  was  ulcer- 
ated on  its  surface. 

*  VicL  Bonct,  Tom.  II.  p.  32. 


[     69     ] 


Scrofulous  swelling  in  the  Pharynx. 

It  has  occurred  to  me  likewise  to  sec  a  scrofulous 
swelling  at  the  lower  end  of  the  pharynx  and  the  be- 
ginning of  the  oesophagus.  When  cut  into  it  appear- 
ed to  consist  of  the  same  kind  of  matter  as  a  scrofu- 
lous absorbent  gland.  It  grew  upon  that  side  of  the 
pharynx  which  is  next  the  larynx,  and  the  patient  for 
this  reason  had  not  only  lost  almost  entirely  the  pow- 
er of  swallowing  but  was  not  able  to  speak  except  in 
the  smallest  whisper. 


Pouch  formed  at  the  lower  end  of  the  Pharynx. 

The  pharynx,  at  its  lower  extremity,  has  been 
known  to  be  dilated  into  a  pouch  of  a  considerable 
size,  which  psssed  behind  the  oesophagus  This 
may  be  supposed  to  be  very  rare,  but  there  is  an  in- 
stance of  it  preserved  in  Dr.  Hunter's  collection. 
The  pouch  in  this  case  began  to  be  formed  in  conse- 
quence of  a  cherry-stone  having  rested  there  for  some 
time,  which  had  made  a  kind  of  bed  for  itself.  It 
remained  in  that  situation  for  three  days,  and  then 
was  brought  up  by  a  violent  fit  of  coughing.  A  part 
of  the  food  always  rested  afterwards  in  the  cavity 
made  by  the  cherry-stone,  by  which  it  was  gradually 
enlarged  At  length,  in  the  course  of  about  five 
years,  the  cavity  was  enlarged  into  a  bag  of  consider- 
able size,  sufficiei  t  to  contain  several  ounces  of  fluid. 
This  bag  passed  down  a  good  way  behind  the  oesoph- 
agus, and  the  oesophagus  necessarily  acquired  a  val- 
vular communication  with  it.  In  porportion  as  the 
bag  enlarged,  this  valvular  communication  would  be- 
come more  and  more  complete,  till  at  length  e\ 
kind  of  food  must  ha\e  rested  in  the  bag,  and  could 
not  pass  into  the  oesophagus  In  this  way  the  person 
was  destroyed.     The    lower  end  of  the  pharynx  is, 


E  0   3 

perhaps,  the  only  part  of  the  canal  where  such  an  ac- 
cident can  happen.  The  pharynx  is  not  contracted 
gradually,  so  as  to  lose  itself  insensibly  in  the  oesoph- 
agus, but  contracts  itself  rather  suddenly  at  the  low- 
er end.  Hence  a  little  recess  is  formed,  in  which  an 
extraneous  body  may  occasionally  rest.  This  would 
be  most  apt  to  happen  at  the  posterior  part ;  so  that  if 
the  recess  should  be  enlarged  into  a  cavity,  it  would 
•generally  pass  behind  the  oesophagus.  The  particu- 
lars of  this  singular  case  have  been  published  in  the 
Medical  observations.* 


The  descending  Aorta, 

There  is  hardly  any  other  disease  of  the  descending 
aorta  within  the  posterior  mediastinum,  than  aneu- 
rysm. This  consists  in  the  aorta  being  a  good  deal 
enlarged  beyond  its  natural  size,  in  its  coats  being  ir- 
regularly thickened,  and  more  readily  divisible  into 
layers  than  in  a  healthy  state.  Little  thin  laminae  of 
bony  matter  are  also  frequently  deposited  behind  the 
inner  membrane.  This  appearance  of  disease,  has 
been  formerly  explained  more  particularly.  It  is  rare 
that  this  part  of  the  aorta  becomes  aneurysmal,  un- 
less there  be  a  general  aneurysmal  affection  over  the 
arterial  system. 

The  Vena  Azygos  varicose. 

The  vena  azygos  is  very  seldom  diseased.  I  have 
seen  it,  however,  varicose,  and  very  much  enlarged. 
This  change  in  it  took  place  from  particular  circum- 
stances. A  considerable  portion  of  the  vena  cava 
inferior  had  become  obliterated  ;  in  consequence  of 
this,  the  usual  vena  azygos,  together  with  an  uncom- 
mon one  on   the   left  side,    were  the  only   channels 

•  See  rbe  Medical  Observations,  Vol,  III.  p.  85. 


r  7i  3 

through  which  the  bleod  could  return  by  a-  circuitous 
route  to  the  heart  ;  they  were  therefore  necessarily, 
from  the  impetus  of  the  blood,  much  enlarged  in  size/ 
and  for  the  same  reason  likewise  varicose.  This 
case  I  have  more  particularly  described  in  the  Medi- 
cal and  Chirurgical  Transactions.* 

Vena  Azygos  ruptured. 

The  vena  azygos  has  been  known  to  be  ruptured, 
when  very  much  distended  with  blood. f  Such  a 
case  has  not  come  under  my  own  observation,  and  I 
believe  it  to  be  very  uncommon. 


The  Thoracic  duct  varicose. 

The  thoracic  duct  also  is  subject  to  very  few  dis- 
eases. I  have  never  seen  any  other  except  that  of  its 
being  very  much  enlarged  and  varicose. 

In  the  instance  to  which  I  allude,  it  was  very  near- 
ly as  large  as  the  usual  size  of  the  subclavian  vein,  but 
nothing  could  be  detected  in  the  neighbouring  parts, 
capable  of  accounting  for  this  appearance.  There 
was  no  obstruction  at  the  entrance  of  the  thoracic  duct 
into  the  venal  system,  which  might  naturallv  hav« 
been  expected.  This  diseased  appearance  of  the  tho- 
racic duct  has  already  been  taken  notice  of  by  Mr. 
Cruikshauk  in  his  treatise  on  the  Absorbent  Sys- 
tem 4 


Thoracic  Duct  obstructed. 

The  thoracic  duct  has  been  known  to  be  obsti  u   ■- 
ed  by  an  earthy  matter  deposited  in  its  cavity,  y     Jt' 

•  Seep.  125,  kc.  Vol.  1. 

t  Vid.  Morgagni,  Epist.  XXVI.  Art.  29- 

\  See  second  edition,  p.  C07  ;  and  it  is  represented  In  M  eajraviflgi  VUte  V, 

§  ViU.  Lieutauel,  Turn.  1J.  p.  93. 


L     72     ] 

docs  not  necessarily  happen  when  the  thoracic  duct  is 
at  some  part  obstructed,  that  chyle  is  prevented  from 
entering  into  the  system  of  blood  vessels.  The  tho- 
racic duct  sometimes  sends  off  one  or  more  considera- 
ble branches,  which  unite  again  with  the  principal 
trunk.  If  under  such  circumstances  an  obstruction 
should  take  place  in  a  part  of  the  principal  trunk,  be- 
tween the  origin  and  the  termination  of  those  branch- 
es, no  bad  effect  would  follow  ;  one  or  more  of  these 
branches  would  become  enlarged,  and  convey  the 
chyle  in  its  full  quantity  to  the  blood. 


Thoracic  Duct  ruptured. 

The  thoracic  duct  has  also  been  known  to  be  rup- 
■tured  ;  although  this  is  exceedingly  rare. 


Absorbent  Glands  scrofulous. 

The  absorbent  glands  in  the  posterior  mediasti- 
num, as  well  as  in  every  other  part  of  the  body,  are 
liable  to  several  diseases.  The  most  common  mor- 
bid affection  is  scrofula.  In  this  case  they  are  fre- 
quentlya  good  deal  enlarged,  and  feel  somewhat  soft- 
er to  the  touch  than  in  their  healtRy  structure. 
When  cut  into,  however,  they  sometimes  exhibit 
very  much  the  natural  appearance  ;  but  it  is  more 
common  to  find  that  some  of  them  contain  a  white, 
soft  cheesy  matter,  mixed  with  a  thick  pus  :  this  is 
the  most  decided  mark  of  scrofulous  affection. 
When  the  absorbent  glands  in  this  situation  are  very 
much  enlarged,  they  necessarily  produce  some  dif- 
ficulty of  breathing,  both  by  pressing  on  the  lungs 
and  the  trachea.  They  may  occasion  also  some  dif- 
ficulty of  swallowing. 


C    73    ] 


Absorbent  Glands  scirrhous* 

I  have  seen  the  absorbent  glands  in  the  neighbour- 
hood of  the  trachea  affected  with  scirrhous,  although 
it  is  a  rare  disease  in  them.  They  were  much  en- 
larged and  very  hard  to  the  touch.  When  cut  into 
they  exhibited  a  harder  texture,  somewhat  intersect- 
ed by  membrane,  so  as  to  resemble  what  is  called 
scirrhous  in  other  parts  of  the  body.  The  trachea 
in  contact  with  these  glands  was  also  affected.  In 
this  case  the  thyroid  gland  was  schirrous,  and  it  is 
probable  that  the  disease  spread  from  the  thyroid  to 
the  absorbent  glands,  and  so  to  the  trachea. 


Absorbent  Glands  bony. 

The  absorbent  glands  near  the  trachea  are  some- 
times converted  into  a  bony  or  earthy  matter  ;  and  I 
think  that  this  disease  is  more  common  in  the  absorb- 
ent glands  at  the  root  of  the  trachea,  than  in  any  oth- 
er part  of  the  body.  These  glands  when  so  diseased, 
by  pressing  against  the  trachea  or  oesophagus,  occa- 
sionally produce  ulcers  in  them. 

The  Anterior  Mediastinum. 

By  the  anterior  mediastinum  is  meant  the  space  in- 
closed between  the  lamina?  of  the  pleura,  which  pass 
from  the  sternum  to  the  pericardium  ;  it  contains  lit- 
tle else  than  cellular  membrane  with  perhaps  a  small 
portion  of  fat ;  and  in  the  younger  subject  the  thymus 
gland. 

It  is  seldom  found  with  any  diseased  appearance  in 
it.  Abscesses  are  occasionally  formed  there,  but 
rarely.     Water  too  is  sometimes  found  in  the  cells 

K 


C     »     ] 

of  its. cellular  membrane.     I  have  also  seen  air  accu- 
mulated in  these  cells. 

Fat  is  occasionally  deposited  in  the  mediastinum 
in  considerable  quantity.  When  the  quantity  is  very 
Targe,  it  has  been  known  to  disturb  the  functions,  both, 
of  the  heart  and  lungs. 


Diseased  Appearances  of  the  Thymus  Gland, 

The  thymus  gland  is  subject  to  few  diseases,  and 
is  only  of  temporary  existence  ;  few  instances  there- 
fore of  morbid  structure  have  been  observed  in  it. 

It  would  seem  to  be  very  little  disposed  to  common 
inflammation  ;  therefore  abscesses  have  occurred  in 
it  very  rarely,  and  have  been  but  little  noticed  by  au- 
thors. 

It  is  more  liable  to  be  enlarged  in  its  size,  and  to 
become  hard  in  its  texture.  It  once  occurred  to  my- 
self to  observe  an  instance  of  this  sort,  but  I  had  not 
an  opportunity  of  examining  it  very  minutely. 

Small  calculi  have  been  said  to  be  occasionally  for- 
med in  the  thymus  gland.* 


SYMPTOMS. 


Inflammation  of  the  thyroid  gland  may  be  "knowre 
by -an  increase  of  its  size  and  firmness,  by  a  pain  felt 
in  it  which  is  increased  upon  pressure,  and  which  is 
probably  also  increased  during  the  act  of  swallowing. 
It  maybe  distinguished  from  some  other  swellings  of 

*  See  Dr.  Soemmsuing's  German  Translation,  p.  61. 


r  "  ] 

this  gland,  as  for  instance  from  bronchocck,  by  its 
rapid  progress,  by  the  feeling  of  pain,  and  by  its  not 
increasing  to  a  very  large  size. 

It  is  worth  while  to  remark,  that  practitioners  ought 
to  be  particularly  cautious  to  prevent  inflammation  of 
the  thyroid  gland  from  advancing  to  suppuration.  If 
it  should  suppurate,  and  the  pus  be  evacuated  exter- 
nally, there  will  be  a  scar  in  the  neck  ;  and  if  it 
should  point  internally,  it  will  probably  make  its  way 
into  the  cavity  of  the  larynx  or  the  trachea,  and  suf- 
focate the  patient.  There  is  a  preparation  in  Dr. 
Hunte-r's  collection,  shewing  this  fatal  termination  of 
inflammation  in  the  thyroid  gland.  Every  means 
should  be  attempted  to  make  the  inflammation  termi- 
nate in  resolution.  When  inflammation  of  the  sub- 
stance of  any  part  terminates  in  resolution,  the  blood 
vessels  gradually  return  to  their  natural  mode  of  ac- 
tion, and  their  natural  size  :  the  deep  seated  absorb- 
ents are  at  the  same  time  excited  to  an  increased  ex- 
ertion, so  as  to  remove  the  blood  and  the  coagulable 
lymph  which  had  been  extra vasated  during  the  inflam- 
mation. This  is  one  of  the  chief  uses  of  the  absorb- 
ent vessels  which  are  distributed  through  tl\e  sub- 
stance  of  parts** 


Bronchocele  may  be  distinguished  from  other  swel- 
lings of  the  thyroid  gland,  by  its  slow  growth,  by  the 
size  at  which  it  is  capable  of  arriving,  by   its  want  of 

*  In  the  reduction  of  some  of  the  deeper  seated  parts  of  the  body  from  a 
sta'e  of  enlargement  to  their  natural  size,  there  is  a  strong  proof  of  a  const  ni 
or  Si  mpathy  existing  between  the  superficial  and  deeper  seated  absorbent  ves- 
.  i  Is.  When,  for  instance,  a  swelled  testicle  is  reduced  to  its  natural  size  by 
robbing  mercurial  ointment  upon  the  surface  of  the  scrotum  which  covers  it, 
it  cannot  be  supposed  that  anv  part  of  the  ointment  comes  in  contact  with  tho 
absorbent  vessels  belonging  to  the  substance  of  the  testicle  ;  yet  these  absorb* 
ire  excited  to  an  increased  action  by  'he  application  of  the  ointment,  and 
the  testicle  is  at  length  reduced    to  its  natural  size.     This  eiVect   would 

apab'e  bf   beinjr  explained  upon  the  principle  of  a  consent  or  s\  mpatl  j 
existing  between  the  absorbents  ofthe  scrotum  and  the  absorbents  of  the  sub- 
stance  of  the  testicle,  by  which,  when  toe  former  are  stimulated,  the   latter 
ised  to  an  increai  ed  action. 


pain,  by  its  commonly  occurring  at  an  early  period  of 
life,  by  the  sensation  it  yields  to  the  touch,  which  is 
that  of  more  or  less  firmness,  but  not  of  great  hard- 
ness, and  by  the  health  being  unaffected  by  it. 


Scirrhous  of  the  thyroid  gland  may  be  distinguish- 
ed from  other  swellings  of  it,  by  its  great  hardness, 
by  occasional  darting  pains  in  the  gland,  and  by  this 
affection  being  most  apt  to  occur  in  persons  of  an  ad- 
vanced age.  The  swelling  likewise  in  scirrhous  of 
the  thyroid  gland  is  seldom  so  large  as  in  broncho- 
cele. 


Ossification  in  the  thyroid  gland  can  only  be  ascer- 
tained by  an  accurate  examination  of  the  part  affected. 
If  the  ossification  be  upon  the  surface  of  the  gland, 
the  bony  matter  will  be  distinctly  felt  under  the  skin  ; 
but  if  it  should  be  deeply  seated,  it  will  be  felt  more 
obscurely,  so  as  to  leave  the  nature  of  the  disease  in 
some  doubt.  When,  however,  it  has  made  further 
progress,  it  will  become  perfectly  distinct. 


When  the  cartilages  of  the  larynx  are  converted  in- 
to bone,  the  voice  has  been  remarked  to  become 
hoarse,  or  sometimes  to  be  changed  into  a  whisper. 
This  may  be  easily  explained,  by  the  cartilages  of  the 
larynx  having  lost  their  flexibility,  and  therefore  be- 
ing rendered  incapable  of  those  finer  motions  which 
it  is  reasonable  to  imagine  must  have  considerable  in- 
fluence upon  the  voice  In  the  cases  which  I  have  had 
an  opportunity  of  examining,  the  ligaments  which  join 
the  cartilages  together  were  natural  in  their  struc- 
ture ;  had  they  been  changed  into  bone,  all  the  mo- 
tions of  the  larynx  would  have  been  lost.  It  would 
then  have  been  useless  as  the  chief  instrument  of 


[     77     ] 

voice  ;  but  what  would  be  the  exact  effect  of  such  a 
change  upon  various  sounds  transmitted  through  the 
trachea  and  the  larynx,  it  is  extremely  difficult  to 
determine.  In  some  instances  where  the  cartilages 
of  the  larynx  have  been  converted  into  bone,  there 
has  occurred  a  total  inability  of  swallowing,  which  de- 
stroyed the  patients.  Upon  examination  after  death, 
no  disease  was  observable  either  in  the  pharynx  or 
the  oesophagus.  How  this  should  happen  it  is  very 
difficult  to  explain,  but  it  has  been  observed  by  Dr. 
Robertson,  the  Physician  of  Greenwich  Hospital. 


When  ulcers  have  taken  place  in  the  cavity  of  the 
larynx,  there  is  a  fixed  pain  in  the  situation  of 
this  organ,  difficulty  of  breathing  and  the  patient  can 
only  speak  in  a  whisper.  This  state  of  the  larynx  is 
accompanied  with  more  or  less  of  symptomatic  fever. 

• 


The  symptoms  which  attend  catarrh  are  too  gener- 
ally known  to  require  being  mentioned.  When  there 
is  a  sense  of  soreness  in  this  disease,  passing  down 
the  middle  of  the  chest,  it  arises  from  a  considerable 
inflammation  of  the  inner  membrane  of  the  trachea. 
This  inflammation  soon  goes  ofl",  but  the  increased 
•secretion  from  the  glands  of  the  trachea  often  remains 
for  a  good  while  afterwards. 

The  inflammation  of  the  inner  membrane  of  the 
trachea,  which  is  sometimes  to  be  found  in  consump- 
tive patients,  continues  for  a  much  longer  time  than 
in  catarrh,  and  may  be  said  to  be  chronic. 


The  symptoms  of  the  croup  are,  symptomatic  fe- 
ver, difficulty  of  breathing,  a  wheezing  or  choaking 
noise  in  inspiration,  a  hoarse  voice,  and  a  sort  of  ring- 
ing sound  during  coughing  ;  portions  of  a  whitish 
membrane  and  pus  are  at  the  same  time  occasionally 


[     ™     ] 

•coughed  up.  It  may  perhaps  be  reasonable  to  sup^ 
pose  that  the  whitish  membrane  is  formed  by  some 
peculiar  action  of  the  blood  vessels  of  the  inner  sur- 
face of  the  larynx  and  the  trachea,  which  is  superad- 
ded to  inflammation.  In  common  inflammation  of* 
the  inner  surface  of  the  larynx  and  trachea,  there  is 
merely  an  increased  secretion  of  mucus,  or  some- 
times of  pus  ;  but  in  the  croup  an  adventitious  mem- 
brane is  always  formed.  This  gives  some  probabili- 
ty to  .the  supposition  which  we  have  made;  and  it 
may  perhaps  serve  to  explain  why  the  croup  is  so 
rarely  cured  by  the  means  which  are  known'to  remove 
common  inflammation. 


The  symptoms  which  attend  a  polypus  of  the 
trachea  are,  difficulty  of  breathing,  a  dry  cough,  and 
a  frequent  pulse,  but  without  any  signs  of  inflamma- 
tion. These,  ghowever,  would  not  enable  physicians 
to  discriminate  this  disease  from  several  others,  if 
portions  of  the  polypus  were  not  frequently  coughed 
up.  The  disease  is  apt  to  continue  for  a  great  length 
of  time. 


The  symptoms  attending  spasmodic  stricture  of  the 
oesophagus  characterize  sufficiently  the  nature  of  the 
disease.  The  difficulty  of  swallowing  is  not  constant, 
but  occasional.  It  comes  on  and  goes  off  suddenly, 
and  these  changes  are  frequent.  There  is  no  ema- 
ciation of  the  body,  and  the  person  generally  seems 
to  be  in  good  health. 


The  stricture  of  the  oesophagus  which  depends  up- 
on the  puckering  of  the  inner  membrane,  is  slow  in. 
its   progress.     It  may    continue  fgr   a   great  many- 
years,  and  the  person  seems  to  be  in  good  health,  ex- 
cept for  the  difficulty  of  swallowing.     The  difficulty 


E     79     ] 

rs  constant,  which  will  distinguish  it  from  a  mere 
spasmodic  contraction  of  the  muscular  fibres  of  the 
oesophagus. 


The  symptoms  which  belong  to  a  stricture  of  the 
eesophagus  depending  on  a  scirrhous  thickening  and 
ulcer,  distinguish  it  sufficiently  from  the  other  two 
diseases.  The  difficulty  of  swallowing  is  small  at 
first,  and  gradually  becomes  worse  but  is  constant. 
When  the  disease  has  made  considerable  progress, 
the  food  is  frequently  rejected,  and  along  with  it  oc- 
casionally there  passes  up  some  pus.  The  pulse  at 
first  is  natural,  but  in  the  advanced  stages  of  the  com- 
plaint, is  frequent  ;  and  towards  its  termination  the 
body  becomes  extremely  emaciated.  The  parts  in 
the  neighbourhood  of  the  disease  are  irritated  to  an 
increased  secretion,  which  often  produc»s  a  cough  or 
hawking.  Although  hardly  any  nourishment,  to- 
wards the  end  of  this  disease,  can  be  got  into  the 
stomach,  yet  the  feeling  of  hunger  is  described  as  not 
being  distresssing. 


Where  there  is  a  fungus  or  a  scrofulous  tumour 
in  the  oesophagus,  the  symptoms  correspond,  I  be- 
lieve, very  much  with  those  of  the  scirrhous  stricture 
of  the  oesophagus  just  described. 


L    so   ] 


CHAP.  VI. 


DISEASED  APPEARANCES  WITHIN  THE.  CAVITY  OF 
THE    ABDOMEN. 


Ascites* 


xVSCITES,  or  dropsy  of  the  cavity  of  the  abdo- 
men, is  a  very  frequent  disease,  and  is  not  confined 
to  any  sex  or  age.  I  have  seen  several  instances  of 
it  in  children  under  ten  years  old  ;  but  it  is  much 
more  common  at  the  middle,  and  the  more  advanced 
periods  of  life.  It  is  also  more  common  in  the  male 
than  the  female  sex.  When  water  is  accumulated  in 
a  large  quantity  in  the  cavity  of  the  abdomen,  the  su- 
perficial veins  of  the  belly  are  generally  a  good  deal 
distended  with  blood  ;  this  probably  arises  from  the 
pressure  of  the  water  upon  the  deeper  seated  veins  ; 
but  it  is  sometimes  hardly  observable,  even  when  the 
accumulation  of  the  water  is  very  considerable.  '  The 
skin  at  the  navel  is  also  often  protruded,  yielding  ea- 
sily to  pressure,  but  this  is  not  universally  the  case. 
On  many  occasions  the  protrusion  can  hardly  be  seen, 
though  the  water  be  accumulated  in  large  quantity. 
Li  opening  into  the  cavity  of  the  abdomen,  there  is 
to  be  seen  a  larger  or  less  quantity  of  an  aqueous  flu- 
id, generally  of  a  brownish  colour,  but  its  colour  va- 
ries according  to  circumstances.  When  there  is  a 
scirrhous  liver  accompanying  the  dropsy,  the  water 


C   si  ] 

is  commonly  of  a  yellowish  or  greenish  colour.  This 
arises  from  a  mixture  of  the  bile  with  the  water,  and 
under  such  circumstances  there  is  almost  always  a 
jaundiced  colour  of  the  skin.  I  have  seen  the  water  . 
in  ascites  of  a  chocolate  or  coffee  colour  ;  but  this  ap- 
pearance is  rare.  In  the  case  to  which  I  allude,  the 
water  is  thicker  than  that  of  ascites  usually  is  ;  but  it 
had  the  common  properties,  as  far  as  could  be  known 
from  the  application  of  heat  and  of  ascids.  When 
none  of  the  viscera  of  the  abdomen  are  diseased  the 
water  in  ascites  resembles  the  serum  of  the  blood  in 
its  colour,  as  well  as  in  its  other  properties. 

While  water  is  accumulated  in  the  cavity  of  the 
abdomen,  .the  intestinal  canal  is  frequently  found  to 
be  somewhat  in  a  contracted  state  ;  but  often  too  this 
is  not  observable.  In  many  cases  of  ascites  the  liver 
is  diseased,  being  hard  and  tuberculated,  as  we  shall 
explain  particularly  when  treating  of  the  diseases  of 
the  liver.  In  some  cases  too,  the  spleen  has  been 
found  to  be  enlarged  and  hard. 

The  ascites  is  not  necessarily  connected  with  the 
accumulation  of  water  any  where  else  in  the  body  ; 
but  it  frequently  happens  that  it  is  accompanied  with 
the  accumulation  of  water  in  the  chest,  and  under 
the  skin,  particularly  of  the  lower  extremities. 


Inflammation  of  the  Peritoneum. 

The  peritonaeum  is  not  uncommonly  inflamed,  al- 
though it  is  by  no  means  so  liable  to  this  disease  as 
the  pleura.  There  is  a  cause  of  inflammation  in  it 
peculiar  to  women,  which  depends  on  a  certain  state 
of  the  womb  after  parturition;  but  there  is  also  a  va- 
riety of  causes  producing  it,  which  are  equally  appli- 
cable to  both  sexes,  so  that  it  is  frequently  found  in 
men,  and  also  in  women  who  have  not  been  preg- 
nant. 

L 


t     82     ] 

When  inflammation  has  taken  place  in  the*peritonae^ 
um,  several  appearances  are  observable  in  opening 
lire  body.  The  peritonaeum  is  thicker  than  in  its 
natural  state,  more  pulpy,  and  less  transparent ;  and 
it  is  crowded  with  a  number  of  very  small  vessels, 
containing  a  florid  blood.  When  a  portion  of  the  in- 
flamed peritonaeum  is  separated  from  the  abdominal 
muscles,,  there  is  commoniyno  appearance  whatev- 
er of  the  inflammation  having  spread  into  the  mus- 
cles ;  but  where  the  peritonaeum  covers  the  intesti- 
nal canal,  the  inflammation  is  sometimes  found  to 
have  penetrated  not  only  info  the  muscular  coat  of  the 
intestines,  but  even  into  the  villous  membrane. 
The  reason  of  this  difference  probably  is,  that  the  pe- 
ritonaeum is  less  connected  with  the  abdominal  mus- 
cles than  with  the  intestinal  canal,  so  that  the  inflam- 
mation passes  less  readily  from  the  peritonaeum  to  the 
former  than  the  latter  part. 

Inflammation  of  the  peritonaeum  is  sometimes 
slight  and  partial  ;  at  other  times  is  great  and  spread 
over  the  whole  membrane.  When  it  is  slight,  and 
affect 3  that  part  of  the  peritonaeum  which  is  connected 
with  the  intestinal  canal,  it  often  forms  broad  surfa- 
ces of  inflammation,  which  run  like  bands  along  the 
course  of  the  intestines,  and  are  bounded  by  the  con- 
tact of  different  portions  of  the  intestines  among  them- 
selves. In  this  case  the  coats  of  the  intestines  are  not 
thicker  than  usual,  the  inflammation  being  slight, 
and  confined  to  the  peritonaeum  itself.  Where  the 
inflammation  is  great,  the  intestines  are  much  thick- 
er, and  more  massy.  This  evidently  arises  from  the 
greater  accumulation  of  blood  in  the  small  blood  ves- 
sels, as  well  as  from  the  extravasation  of  fluids  into 
the  substance  of  the  intestines,  in  consequence  of  the 
strong  inflammatory  action  of  the  vessels.'  The  mes- 
entery and  mesocolon  are  much  thicker  than  in  their 
natural  state,  and  there  is  also  a  remarkable  change 
in  the  omentum.  It  is  frequently  as  thick  as  a  per- 
son's hand,  and  lies  as  a  circumscribed  mass  along 
the  great  curvature  of  the  stomach.     The   principal 


[     «     ] 

cause  of  this  change  in  these  parts,  is  the  extravasa- 
tion of  the  coagulable  lymph  into  the  cellular  mem- 
brane between  the  laminae  of  the  peritonaeum  which 
form  them. 

In  many  places  there  is  thrown  out  a  layer  of  a  yel- 
lowish pulpy  matter,  gluing  different  portions  of  the 
viscera  together.  This  layer  is  sometimes  thin  ;  at 
other  times  is  of  considerable  thickness,  and  ap- 
pears to  be  the  coagulable  lymph  of  the  blood. 
There  is  also  a  considerable  quantity  of  a  brownish 
fluid  in  the  cavity  of  the  abdomen  resembling  the  se- 
rum, which  is  mixed  with  small  shreds  of  the  coagu- 
lable lymph,  and  sometimes  with  pus,  giving  it  a 
turbid  appearance.  The  quantity  of  the  coagulable 
lymph,  and  of  the  fluid,  is  sometimes  large,  in  pro- 
portion to  the  degree  of  the  inflammation.  In  some 
instances,  instead  of  serum  a  large  quantity  of  pus  is 
found.  Air  too  is  sometimes  accumulated  in  the 
stomach  and  the  intestinal  canal,  which  had  been  for- 
med in  the  progress  of  the  disease.  At  other  times 
this  air  is  wanting.  The  accumulation  of  air  is  most 
common  when  the  inflammation  is  slight,  and  passes 
in  bands  along  the  surface  of  the  intestines. 


Adhesions  in  the  Cavity  of  the  Ahdomciu 

When  there  has  been  inflammation  of  the  perito- 
naeum either  generally  or  partially,  sufficient  to  have 
thrown  out  coagulable  lymph,  and  the  patient  lias 
survived  the  disease,  the  coagulable  lymph  is  chan- 
ged into  a  line  transparent  membrane,  which  is  the 
membrane  of  adhesions.  The  time  which  is  occu- 
pied in  the  change  of  the  coagulable  lymph  into  the 
membrane  of  adhesions,  is  not  very  long;  for  I  have 
had  several  opportunities  of  tracing  the  gradual  pro- 
gress of  the  change  from  the  one  into  the  other,  while 
the  inflammation  appeared  to  have  been  recent.  This 
membrane  consists  of  a  cellular  substance,  similar  to 
the  general  cellular  membrane  of  the  body,  and  has  a 


[     84     ] 

moderate  share  of  vascularity.  It  does  not  naturally 
shew  many  vessels  large  enough  to  admit  the  red 
globules  of  the  blood  ;  but  it  shews  its  vascularity 
upon  slight  degrees  of  inflammation,  or  when  its  ves- 
sels have  been  filled  with  the  fine  injection.  This 
membrane  is  capable  of  elongating  gradually  by  the 
motion  of  the  viscera  upon  themselves,  so  as  ulti- 
mately to  be  attended  with  very  little  inconvenience. 
I  have  very  often  had  an  opportunity  of  observing 
these  adhesions,  either  joining  all  the  viscera  of  the 
abdomen  more  or  less  together,  or  joining  some  par- 
ticular viscera  to  each  other. 


Scrofulous  Masses  adhering  to  the  Peritonaeum. 

I  have  several  times  had  an  opportunity  of  observ- 
ing a  white  soft  granulated  matter  adhering  universal- 
ly behind  the  peritonaeum.  In  some  places  it  formed 
a  mass  of  considerable  thickness  ;  in  others,  it  was 
scattered  in  single  small  masses.  In  one  case  I  recol- 
lect that  it  formed  a  substance  as  thick  as  my  hand, 
between  the  peritonaeum  and  the  abdominal  muscles, 
while  it  was  scattered  in  small  separate  portions  in  the 
mesentery  and  the  peritonaeum,  covering  the  intesti- 
nal canal.  The  omentum  I  have  sometimes  seen 
changed  into  a  cake  of  this  substance.  The  matter 
itself  appears  to  be  scrofulous,  for  it  resembles  ex- 
actly the  structure  of  a  scrofulous  absorbent  gland  be- 
fore pus  is  actually  formed.  I  am  not  at  all  certain 
how  far  this  appearance  of  disease  should  have  been 
classed  along  with  those  of  the  peritonaeum  :  it  does 
not  take  place  (at  least  in  the  cases  which  I  have 
seen)  in  the  peritonaeum  itself,  but  behind  it,  yet  at 
the  same  time  adhering  to  it.  It  appears,  however, 
upon  the  whole  to  be  placed  here  with  more  proprie- 
ty than  it  could  have  been  any  where  else- 


.[     85     3 


Cancerous  Tumours  adhering  to  the  Peritonaeum. 

I  have  also  seen  some  small  cancerous  tumours 
growing  from  the  peritonaeum.  These  were  ex- 
tremely hard,  of  a  white  colour,  and  resembled  ex- 
actly  in  their  structure  the  cancerous  masses  which 
are  formed  in  the  stomach.  What  puts  the  appear- 
ance I  allude  to  beyond  doubt,  is,  that  in  the  same 
bodv  I  found  a  cancerous   tumour  of  the  stomach. 

The  cancerous  tumours  of  the  peritonaeum  were 
not  at  all  connected  with  this  other,  but  were  in  that 
part  of  the  membrane  which  lines  the  recti  abdominis 
muscles,  nearly  opposite  to  the  region  of  the  stomacL- 


Cartilaginous  Excrescences  growing  from  the  Perito- 
neum. 

In  one  case  I  have  seen  a  great  many  cartilaginous 
excrescences  growing  from  the  periton  -  um.  They 
were  of  a  small  size,  viz.  most  of  them  not  larger 
than  a  garden  pea,  and  grew  from  every  part  of  the 
membrane.  They  were  a  little  softer  than  the  carti- 
lages which  cover  the  extremities  of  the  bones,  but 
had  the  true  structure  of  cartilage. 


Stcatotnatous   Turnout's  adhering   to  the  Peritoneum. 

Steatomatous  tumours  have  also  been  observed  ad- 
hering to  the  peritonaeum  ;  but  these  are  of  very  rare 
occurrence.* 

•Sec  Soemmerring's  Germ,  Translat.  p.  TO. 


C     86     ] 


Hydatids  in  the  Abdomen. 

Hydatids  have  occasionally  been  found  to  occupy 
a  portion,  or  even  the  whole,  of  the  cavity  of  the 
abdomen.  In  such  cases  they  are  connected  with  the 
viscera,  and  chiefly  with  the  liver  or  the  spleen. 
They  may,  however,  be  attached  to  any  viscus  or  to 
any  part  of  the  peritonaeum.  This  appearance  of  dis- 
ease is  uncommon. 


Air  in  the  Cavity  of  the  Abdomen. 

Air  has  been  said  to  be  occasionally  accumulated 
in  the  cavity  of  the  abdomen,  while  little  or  none  is 
contained  in  the  intestines.*  This  I  believe  to  be  a 
very  rare  occurrence.  Air  is  not  unfrequently  accu- 
mulated in  considerable  quantity  in  the  intestinal  canal, 
while  there  is  none  at  all  in  the  cavity  of  the  abdomen. 
When  a  large  quantity  of  air  is  accumulated  in  the 
bowels,  they  become  greatly  distended,  and  their  coats 
proportionably  thin.  Bythe  bowels  lying  in  close  con- 
tact with  the  peritonaeum  which  lines  the  muscular 
parites  of  the  abdomen,  there  is  the  same  feeling  of 
distension  when  the  hand  is  pressed  against  the  sur- 
face of  the  belly,  and  the  same  quick  reaction  upon 
removing  the  hand,  as  if  the  cavity  of  the  belly  it- 
self had  been  filled  with  air.  This  has  probably  giv- 
en rise  to  the  opinion,  that  the  air  is  often  contained 
in  the  cavity  of  the  belly.  I  can  believe,  however, 
that  air  may  on  some  occasions  be  accumulated  hi 
the  cavity  of  the  belly,  but  this  is  very  uncommon. 
A  part  of  the  intestine  when  very  much  distended 
with  air  may  burst,  and  a  portion  of  the  air  may  es- 
cape into  the  cavity  of  the  belly  ;  or  the  small  arte- 
ries of  the  peritonaeum  may  secrete  air   in  the  same 

*  Vid.  Lfesratid,  Tom.  I    p   432. 


C     87     ] 

.manner  as  it  appears  to  be  formed  by  the  inner  merfr- 
brane  of  the  stomach  and  the  intestines. 


SYMPTOMS, 


The  symptoms  which  belong  to  ascites  are  almost 
too  well  known  to  require  being  mentioned.  There 
is  commonly  a  distinct  feeling  of  fluctuation  upon  ap- 
plying one  hand  to  the  bell}-,  and  striking  it  with  the 
other  ;  the  urine  is  in  small  quantity,  and  of  a  deep 
colour  ;  there  is  thirst,  often  some  feeling  of  heat, 
and  a  pulse  more  frequent  than  in  health.  The 
breathing  is  likewise  diflicult  when  the  water  is  accu- 
mulated in  very  large  quantity. 


The  symptoms  attending  inflammation  of  the  pe- 
ritonaeum are  a  pain  in  the  abdomen,  together  with 
some  swelling  there,  and  a  great  sense  of  soreness  to 
the  touch  The  bowels  are  often  costive,  the  pulse 
is  frequent  and  hard,  and  there  are  the  other  circum- 
stances of  symptomatic  fever  strongly  marked. 
When  the  inflammation  is  slight,  I  have  known  the 
pain  to  be  very  inconsiderable,  aiid  the  pulse  to  be 
little  increased  in  its  frequency,  so  that  inflammation 
of  the  peritonaeum  had  not  been  suspected.  Upon 
examination,  however,  of  the  body  after  death,  m> 
other  diseased  appearance  than  a  slight  inflammation 
of  the  pcritjonxum  was  discoverable. 


[     88     ] 


There  are  no  symptoms  which  mark  the  existence 
of  adhesions  in  the  abdomen  ;  and  they  seem  to  be 
attended  with  no  inconvenience  to  the  functions  which 
are  carried  on  in  that  cavity. 


The  symptoms  which  belong  to  scrofulous  and 
scirrhous  tumours  of  the  peritonaeum  are  unknown 
to  me. 

I  know  of  no  symptoms  produced  by  cartilaginous 
excrescences  growing  from  the  peritonaeum.  It  is 
probable  that  they  are  generally  not  observable,  or 
not  capable  of  being  discriminated. 


When  hydatids  are  accumulated  in  large  quantity 
in  the  abdomen,  it  will  require  some  attention  to  dis- 
tinguish this  disease  from  ascites.  It  may  be  distin- 
guished however  in  the  following  manner.  In  the 
case  of  hydatids,  the  feeling  of  fluctuation  upon  strik- 
ing the  belly  with  the  hand  will  either  take  place  very 
indistinctly,  or  not  at  all  ;  whereas  in  ascites  attended 
with  no  extraordinary  symptoms,  it  is  always  distinct. 
The  swelling  in  ascites  is  always  uniform,  but  in  an 
accumulation  of  hydatids  it  will  be  more  or  less  une- 
qual. In  hydatids  it  will  be  found,  upon  euquiry  in- 
to the  history  of  the  case,  that  the  swelling  first  began 
in  some  determined  place,  whereas  in  ascites  there  is 
a  gradual  swelling  of  the  whole  belly. 

It  will  be  more  difficult  to  distinguish  an  accumu- 
lation of  hydatids  from  a  dropsy  of  the  ovarium  than 
from  ascites.  The  distinction  between  the  two  dis- 
eases would  seem  only  capable  of  being  determined 
by  an  accurate  inquiry  into  the  history  of  the  case. 
In  dropsy  of  the  ovarium  the  swelling  is  first  perceiv- 
ed on  the  side  of  the  lower  part  of  the  belly,  and 
gradually  increases  upwards,  so  as  to  occupy  a  great 


C     89     ] 

part  cf  the  cavity  of  the  abdomen.  As  hydatids  most 
commonly  grow  from  the  liver,  the  swelling  in  this 
case  will  generally  be  first  sensible  at  the  upper  part 
of  the  belly,  and  spread  downwards.  Hydatids, 
however,  may  be  formed  in  any  part  of  the  abdomen, 
and  therefore  were  they  to  begin  to  be  formed  at  the 
side  of  the  lower  part  of  the  belly,  it  seems  hardly 
possible  to  distinguish  the  one  disease  from  the  other. 


M 


?aorn  eblhl 

Jinq   rxjqn  : 
.abilubvK 
tmrnobdc  3ii 
arlr  Js  bonnbi 
ylbjfjrf   zmooi 
.I'jdio  odi  mo 


[    so   3 


CHAP.  VII. 


BISEASED    APPEARANCES    OF    THE    STOMACH, 


Inflammation. 


JLT  sometimes  happens,  although  not  very  frequent* 
]y  (unless  poisons  have  been  swallowed)  that  inflam- 
mation takes  place  in  the  stomach,  and  spreads  over 
a  very  considerable  portion  of  its  inner  membrane,  or 
perhaps  the  whole  of  it.  It  is  much  more  common 
for  inflammation  to  occupy  a  smaller  portion  of  the 
stomach.  In  such  cases  the  inflammation  is  general- 
ly not  very  violent.  The  stomach  upon  the  outside, 
at  the  inflamed  part,  shews  a  greater  number  of 
small  vessels  than  usual,  but  is  commonly  not  much 
crowded  with  them.  On  opening  into  the  stomach,  it 
is  found  to  be  a  little  thicker  at.  the  inflamed  part,  the 
inner  membrane  is  very  red  from  the  number  of  small 
florid  vessels,  and  there  are  generally  spots  of  ex- 
travasated  blood.  It  does  not  often  occur  that  a  com- 
mon inflammation  of  the  stomach  proceeds  to  form 
pus,  or  to  terminate  in  gangrene. 

When  arsenic  has  been  swallowed  (which  is  the 
poison  most  frequently  taken)  the  stomach  is  affected 
with  a  most  intense  degree  of  inflammation.  Its  sub- 
stance  becomes  thicker,  and  there  is  a  very  gqCatde* 


[     91     ] 

gree  of  redness  in  the  inner  membrane,  arising  partly 
from  the  very  great  number  of  minute  vessels,  and 
partly  from  extravasated  blood.  Portions  of  the  in- 
ner membrane  are  sometimes  destroyed,,  from  the  vi- 
olent action  that  has  taken  place  in  c^n^eVjuefi&P  of 
the  immediate  application  of  the  poisohi:TjI;tta?ve:als6 
seen  a  thin  layer  of  coagulablc  lymph*thi*6^\#it'vi}y.»' 
on  a  portion  of  the  inner  surface  of  (the^srtom-aeh. 
Most  commonly  too,  some  part  of  th^afsefticis"  to  be1 
ccen  in  the  form  of  a  white  powder,  lying  M^oneliffe*^ 
ent  portions  of  the  inner  membrane. ,(-  r'fraVe'beeiT  ifid 
formed,  that  in  two  cases  where  arsenic  had  bceiv 
swallowed,  and  had  destroyed  the  pcrs^HYs-^'prcidu^ 
cing  violent  inflammation  of  the  stomach,  ulcers  -wcFe^ 
found  upon  examination  after  death,  attf^'low'ercnd* 
of  the  rectum.  These  persons  had  never  complained' 
of  any  disease  in  the  rectum  previously  t$  &wallovfriri|* 
the  arsenic,  and  were  apparently  in  good' heAltfA 
This  circumstance  is  very  extraordinary,  but  it  is* 
stated  from  good  authority  ;  and  it  is  well  Wortiv'en* 
(jiiiry,  how  far  the  rectum  is  commonly  affected  "j>y* 
swallowing  arsenic.  It  is  possible  that  some' peculiar 
sympathy  may  be  established  between  the  ibw^r  end 
of  the  rectum  and  the  stomach,  where  violent rinflam*> 
rnation  has  been  produced  by  swallowing  tlvJs/po?stj>riy 
and  that  the  effect  of  this  sympathy  may  be  thetforTtt&J 
■tion  of  an  ulcer  in  that  part  of  the  great  intebtihe s. 


Appearances  in  the  Hydrophobia.  & 

On  opening  the  bodies  of  persons  who  havccficd 
from  hydrophobia,  the  inner  membrane  of  thestom^ 
ach  is  frequently  found  inflamed  at  the  cardi'*,  and  its 
great  end.  The  inner  membrane  of  the  pharynx  and! 
the  oesophagus  is  also  inflamed.  The  membrane  is 
not  thickened  by  the  inflammation,  but  the  inflamma- 
tion spreads  as  in  erysipelas,  shewing  in  sonie  iplaacq 
a  distinct  line  of  boundary.  This  inflammation  \  foeo 
•Jievc  is  commonly  not  violent. 


C     92     ] 


Ulcers  of  the  Stomach. 

Opportunities  occasionally  offer  themselves  of  ob- 
serving ulcers  of  the  stomach.  These  sometimes  re- 
semble common  ulcers  in  any  other  part  of  the  body, 
but  frequently  they  have  a  peculiar  appearance.  Ma- 
ny of  them  are  scarcely  surrounded  with  any  inflam- 
mation, have  not  irregular  eroded  edges  as  ulcers 
have  generally,  and  are  not  attended  with  any  particu- 
lar diseased  alteration  in  the  structure  of  the  stomach 
in  the  neighbourhood.  They  appear  very  much  as 
if,  some  little  time  before,  a  part  had  been  cut  out 
from  the  stomach  with  a  knife,  and  the  edges  had 
healed,  so  as  to  present  an  uniform  smooth  bounda- 
ry round  the  excavation  which  had  been  made. 
These  ulcers  sometimes  destroy  only  a  portion  of  the 
inner  coat  of  the  stomach  at  some  one  part,  but  occa- 
sionally they  destroy  a  portion  of  all  the  coats,  form- 
ing a  hole  in  the  stomach.  When  a  portion  of  all  the 
coats  is  destrojed,  there  is  sometimes  a  thin  appear- 
ance of  the  stomach  surrounding  the  hole,  which  has 
a  smooth  surface,  and  depends  on  the  progress  of  the 
ulceration.  At  other  times,  the  stomach  is  a  little 
thickened  round  the  hole  ;  and  at  other  times  still,  it 
seems  to  have  the  common  natural  structure. 

Scirrhous  and  Cancer  of  the  Stomach. 

This  affection  of  the  stomach  is  not  very  uncom- 
mon towards  an  advanced  period  of  life,  and  I  think 
is  more  frequently  met  with  in  men  than  in  women. 
This  may  probably  depend  upon  the  greater  intem- 
perance m  the  one  sex  than  in  the  other. 

Scirrhous  sometimes  extends  over  almost  every 
part  of  the  stomach,  but  most  commonly  it  attacks 
one  part.  The  part  which  is  affected  with  scirrhous 
has  sometimes  no  very  distinct  limit  between  it  and 


C     93     ] 

the  sound  structure  of  the  stomach,  but  most  com- 
monly the  limit  is  very  well  marked.  When  scir- 
rhous attacks  a  portion  of  the  stomach  only,  it  is 
generally  towards  the  pylorus.  The  principal  reason 
of  this  probably  is,  that  there  is  more  of  glandular 
structure  in  that  part  of  the  stomach  than  in  any  oth- 
er ;  and  it  would  appear  that  glandular  parts  of  the 
body  are  more  liable  to  be  affected  with  scirrhous  than 
other  parts. 

When  the  whole  stomach,  or  a  portion  of  it,  is 
scirrhous,  it  is  much  thicker  than  usual,  as  well  as 
much  harder  in  its  texture.  When  the  diseased  par: 
is  cut  into,  the  original  structure  of  the  stomach  is 
frequently  marked  with  sufficient  distinctness,  but 
very  much  altered  from  the  natural  appearance.  The 
peritonasal  covering  of  the  stomach  is  many  times 
thicker  than  it  ought  to  be,  and  has  almost  a  gristly 
hardness.  The  muscular  part  is  also  very  much 
thickened,  and  is  intersected  by  numerous  membran- 
ous septa.  These  membranous  septa  are,  probably, 
nothing  else  than  the  cellular  membrane  intervening 
between  the  fasciculi  of  the  muscular  fibres,  thicken- 
ed from  disease.  The  inner  membrane  is  also  ex- 
tremely thick  and  hard,  and  not  (infrequently  some- 
what tuberculated  or  irregularly  elevated  towards  the 
cavity  of  the  stomach. 

It  frequently  happens  that  this  thickened  mass  is 
ulcerated  upon  its  surface,  and  then  a  stomach  is  said 
to  be  cancerous.  Sometimes  the  inner  membrane  of 
the  stomach  throws  out  a  process  which  terminates  in 
a  great  many  smaller  processes,  and  produces  what 
has  been  commonly  called  a  fungous  appearance. 

It  also  happens  that  the  stomach  at  some  part  loses 
entirely  all  vestige  of  its  natural  structure,  and  is 
changed  into  a  very  hard  mass,  of  a  whitish  colour, 
with  some  appearance  of  membrane  intersecting  it  : 
or  it  is  converted  into  a  gristly  substance,  like  car- 
tilage somewhat  softened.  The  absorbent  glands  in 
the  neighbourhood  are  at  the  same  time  coramonlv  en- 
larged,  and  have  a  very  hard,  white  structure. 


C    m   ] 


^Circumscribed  scirrhous  Tumours  in  the  Stomath. 

I  have  seen  several  instances  of  a  scirrhous  tumour 
being  formed  in  the  stomach  about  the  size  of  a  wal- 
nut, while  every  other  part  of  it  was  healthy.  This 
tumour  has  most  frequently  a  small  depression  near 
the  middle  of  its  surface.  While  it  remains  free  from 
irritation,  the  functions  of  the  stomach  arc  probably 
very  little  affected  by  it  ;  when,  however,  it  is  irrita- 
ted, it  must  occasion  very  considerable  disorder  in 
the  functions  of  the  stomach,  and  perhaps  lay  the 
foundation  of  a  fatal  disease. 


Pouch  formed  in  the  Stomach. 

A  part  of  the  stomach  is  occasionally  formed  into  a 
pouch  by  mechanical  means,  although  very  rarely. 
I  have  seen  one  instance  of  a  pouch  being  so  formed, 
in  which  five  halfpence  had  been  lodged.  The  coats 
of  the  stomach  were  thinner  at  that  part,  but  were  not 
inflamed  or  ulcerated.  The  halfpence  had  remained 
there  for  some  considerable  time,  forming  a  pouch 
by  their  pressure,  but  had  not  irritated  the  stomach 
in  such  a  manner  as  to  produce  inflammation  or  ulcer*. 
ation. 


Stricture  at  the  Pylorus. 

The  orifice  of  the  stomach  may  be  almost,  or  per~ 
baps  entirely,  shut  up  by  a  permanent  contraction  of 
its  muscular  fibres,  either  at  the  cardia  or  the  pylo- 
rus. This  is  more  likely  however,  to  occur  often  est 
at  the  pylorus,  because  the  fibres  at  this  end  of  the 
stomach  are  more  circular  in  their  direction,  and  pos- 
sess a  stronger  contractile  power.  Less  contraction 
too,  at  the  pylorus,  will  produce  an  obstruction  in 
the  canal,  than   at  the  cardia.     I  have  seen  ojic  in- 


[     95     ] 

stance  of  this  contraction  at  the  p\lorus,  which,  even 
there,  is  a  very  rare  disease.  The  contraction  was 
so  great  as  hardly  to  admit  a  common  goose  quil  to 
pass  from  the  stomach  into  the  duodenum,  and  it  had 
prevented  a  number  of  plumb  stones  from  passing, 
which  were  therefore  detained  in  the  stomach. 


Stomach  much  contracted,  or  much  enlarged. 

The  stomach  is  sometimes  found  so  contracted 
through  the  whole  of  its  extent  as  not  to  be  larger 
than  a  portion  of  the  small  intestine  ;  and  sometimes 
it  is  enlarged  to  much  more  than  its  ordinary  size. 
Neither  of  these  appearances  are  to  be  considered  as 
arising  from  disease.  They  depend  entirely  on  the 
muscular  fibres  of  the  stomach  being  in  a  state  of  con- 
traction or  relaxation  at  the  time  of  death.  It  hap- 
pens, I  think,  more  frequently  that  the  stomach  is 
dilated  than  contracted. 


Stomach  distended  with  Air. 

The  stomach  Is  very  commonly  found,  in  a  dead 
body,  flaccid  and  almost  empty  ;  but  not  unfrequent- 
ly  it  is  found  more  or  less  distended  with  air  :  this 
air  may  have  been  formed  after  death,  but  it  is  often 
formed  during  life.  When  this  is  the  case  we  may 
suppose  it  to  be  produced  by  a  new  chemical  arrange- 
ment of  the  contents  of  the  stomach  ;  but  it  also  fre- 
quently happens  that  air  is  separated  from  the  blood 
in  the  blood  vessels  of  the  stomach,  and  poured  by  the 
small  exhalents  into  its  cavity.  This  has  been  more 
particularly  taken  notice  of  by  Mr.  Hunter,  in  his 
Essay  upon  Digestion,*  and  by  myself,  in  a  paper 

•  See  Mr.  Huntet's  Qjiwvauons  on  wrtain  parts  of  th.e  animal  ecoTrcmy, 
p.  161- 


[     96     ] 

which  is  published  in  the  Medical  and  Chirurgiccii 
Transactions.* 


Part  of  the  Stomach  dissolved  by  the  Gastric  Juice. 

In  looking  upon  the  coats  of  the  stomach  at  its 
great  end,  a  small  portion  of  them  there  appears  fre- 
quently to  be  thinner,  more  transparent,  and  feels 
somewhat  more  pulpy  than  is  usual  ;  but  these  ap- 
pearances are  seldom  very  strongly  marked.  They 
arise  from  the  gastric  juice  resting  on  that  part  of  the 
stomach  in  greater  quantity  than  on  any  other,  and 
dissolving  a  small  portion  of  its  coats.  This  is  there- 
fore not  to  be  considered  as  the  consequence  of  a  dis- 
ease, but  as  a  natural  effect,  depending  upon  the  ac- 
tion of  the  gastric  juice,  on  the  coats  of  the  stomach 
after  death.  When  the  gastric  juice  has  been  in  con- 
siderable quantity,  and  of  an  active  nature,  the  stom- 
ach has  been  dissolved  quite  through  its  substance  at 
the  great  end,  and  its  contents  have  been  effused  into 
the  general  cavity  of  the  abdomen.  In  such  cases  the 
neighbouring  viscera  are  also  partially  dissolved,. 
The  instances,  however,  of  so  powerful  a  solution 
are  rare,  and  have  almost  only  occurred  in  persons 
who  while  in  good  health  had  died  suddenly  from  ac- 
cident. If  the  powers  of  the  stomach  were  little  im- 
paired by  diseases,  this  appearance  of  the  stomach 
after  death  would  be  very  common.  As,  however, 
they  are  very  much  injured  by  most  diseases,  and  by 
many  are  totally  destroyed,  this  appearance  very  sel- 
dom takes  place.  The  true  explanation  of  these  ap- 
pearances was  first  given  by  Mr.  Hunter,  and  pub- 
lished at  the  request  of  Sir  John  Pringle,  in  the  Phy- 
losophical  Transactions.! 

*  See  caseof  emphysema,  p    202. 

t  See  Philospph.  Transact   Vol.  62,  p.  447% 


C     97     ] 

Fatty  Tumours  in  the  Stomach, 

Tumours,  consisting  of  a  fatty  substance,  have 
been  sometimes  found  in  the  stomach,  but  they  are 
to  be  considered  as  a  very  rare  appearance  of  disease. 
Ruysch  relates  that  he  has  seen  a  tumour  from  the 
stomach  of  a  man  which  contained  hair,  together  with 
some  dentes  molares  ;  and  that  he  has  preserved  this 
in  his  collection.* 


Calculi  in  the  Stomach, 

Calculi  with  different  appearances  have  been  des- 
cribed as  being  occasionally  found  in  the  stomach. 
They  have  never  come  under  my  own  observation, 
and  are  to  be  reckoned  very  uncommon. f  Most  of 
these  calculi  have  been  found  upon  examination  to  be 
biliary,  and  had  been  conveyed  from  the  duodenum 
into  the  stomach  by  an  antiperistaltic  motion  of  this 
part  of  the  small  intestines. 

Morbid  Papillce  observed  in  the  Stomach. 

Papilla?  and  pustules,  somewhat  resembling  the 
small- pox,  have  also  been  described  as  being  formed 
on  the  inneF  membrane  of  the  stomach,  but  these 
are  exceedingly  rare.  J 

Small-pox  Pustules  said  to  be  in  the  Stomach. 

Even  true  small-pox  pustules  hare  been  said  to  be 
found  in  the  stomach  of  persons  who  died  from  this 
disease. §     In  later  dissections,  however,  this  appear- 

•Vid.  Ruysch,  Tom    2-  Adversar.  Anatomicor.  Decad.  Tat. 
t  Vid.  Lieutaud,  Tern.  1.  p.  17. 
\  Vid    Lieutaud,  Tom*  l.p.  23. 
§  Vid.  Lieutaud,  Tom-  1.  p.  371* 

N 


C      93     ] 

ance  has  not  been  observed,  and  I  am  disposed  to 
believe,  where  it  has  been  thought  to  exist,  that  some 
mistake  has  been  made. 


SYMPTOMS. 


In  inflammation  of  the  stomach,  the  following 
symptoms  are  observed  to  take  place  :  viz.  pain  in 
the  epigastric  region,  which  is  increased  when  any 
thing  has  been  swallowed,  vomiting,  often  hickup, 
symptomatic  fever  with  a  small,  frequent,  and  hard 
pulse,  and  a  feeling  of  great  debility. 


The  symptoms  which  are  produced  by  swallowing 
arsenic,  are  the  same  with  those  which  take  place  in 
a  very  violent  inflammation  of  the  stomach  ;  for  arse- 
nic acts  upon  that  organ  in  no  other  way  than  by  ex- 
citing in  it  a  very  high  degree  of  inflammation. 

Hydrophobia  is  sufficiently  characterized  by  the 
horror  which  the  patient  expresses  at  the  sight  of  any 
fluid  that  is  offered  to  him,  by  the  great  difficulty  ex- 
perienced in  swallowing,  and  by  the  strong  alienation 
of  mind  which  accompanies  this  dreadful  disease. 


I  have  reason  to  believe  that  ulcers  of  the  stomach 
arc  often  slow  in  their  progress.  They  are  attended 
with  pain,  or  an  uneasy  feeling  in  the  stomach,  and 
what  is  swallowed  is  frequently  rejected  by  vomiting. 

This  state  continues  for  a  considerable  length  of 
time,  and  is  very  little  relieved  by  medicine  ;  which 


C     99     ] 

may  serve  as  some  ground  of  distinction  between  this 
complaint  and  a  temporary  deranged  action  of  the 
stomach. 


Cancer  of  the  stomach  is  attended  with  a  sense  of 
pain  in  that  organ,  which  varies  a  good  deal  in  its  de- 
gree in  different  individuals.  What  is  swallowed  is 
commonly  rejected  by  vomiting,  and  there  is  frequent- 
ly thrown  up  a  dark  coloured  fluid,  which  has  some- 
times been  compared  to  coffee  grounds.  The  patient 
becomes  at  length  emaciated,  and  the  countenance 
sallow  ;  the  pulse  at  the  beginning  of  this  dreadful 
complaint  is  natural,  but  towards  the  close  of  it  is 
frequent,  and  is  Accompanied  with  the  usual  symp- 
toms of  hectic  fever.  Where  the  person  is  mueh 
emaciated,  and  the  cancerous  swelling  is  situated 
near  the  polyrus  or  along  a  part  of  the  great  curva- 
ture of  the  stomach,  it  may  be  felt,  if  its  bulk  be 
considerable,  by  a  careful  examination  with  the  hand 
in  the  living  body. 


The  accumulation  of  air  in  the  stomach,  is  accom- 
panied witli  an  unpleasant  feeling  of  distention  there, 
and  a  swelling  may  be  felt  externally  in  the  epigas- 
tric region  ;  wind  passes  up  by  the  oesophagus,  and 
there  are  occasional  pains  in  the  stomach  produced 
by  a  spasmodic  contraction  of  some  part  of  its  mus- 
cular coat. 


C    100   ] 


CHAP.  VIII. 


DISEASED   APPEARANCES   IN   THg   INTESTINES. 


Inflammation. 


T 


HE  intestinal  canal  is  subject  to  inflammation 
from  a  variety  of  causes,  and  therefore  we  have  fre- 
quent opportunities  of  observing  its  effects  after 
death.  When  a  portion  of  intestine  is  inflamed, 
there  is  spread  upon  its  outer  surface  a  number  of 
small  vessels,  many  of  which  contain  florid  blood. 
When  the  intestine  is  cut  into,  so  as  to  exhibit  its 
inner  membrane,  this  appears  highly  vascular  from 
the  smal  vessels  of  the  villi  being  loaded  with  blood, 
and  there  are  frequently  to  be  seen  in  it  a  few  spots  of 
blood  extravasated.  In  inflammation  of  the  intes- 
tines, the  peritonaeum  is  often  very  little,  or  not  at 
all  affected.  When,  however,  the  inflammation  is 
very  great,  the  peritonaeum  is  also  inflamed,  and 
covered  with  a  layer  of  coagulable  lymph.  I  have 
likewise  seen,  in  violent  inflammation,  scattered  por- 
tions of  coagulable  lymph  thrown  out  upon  the  sur- 
face of  the  villous  membrane  :  this  however  is  very 
uncommon.  The  intestine  is  at  the  same  time  much 
more  thick  and  massy  than  in  a  healthy  state,  and  its 
colour  is  sometimes  very  dark  from  a  large  quantity 
of  black  extravasated  blood.  This  state  of  the  intes- 
tine has  often  been  mistaken  for  mortification. 

It  very  commonly  happens  that  inflammation  of  the 
intestines  advances  to  suppuration  and  ulceration. 
This  takes  place  where  the  inflammation  is  confined 
principally  to  the  inner  membrane  of  the  intestines. 
The  ulcer  is  formed  upon  the  inner  surface  ;  and  I 


[     101     ] 

do  not  recollect  to  have  seen  one  instance  where  the 
ulcer  had  begun  upon  the  outer  surface  of  the  intes- 
tines and  had  spread  inwards.  Ulceration,  however, 
does  not  appear  to  be  so  common  in  the  small  as  in 
the  great  intestines.  When  it  takes  place  either  in 
the  one  or  the  other  intestine,  it  is  attended  with 
considerablevariety  in  its  appearance  :  the  edges  of  the 
ulcer  have  sometimes  considerable  thickness  ;  and 
sometimes  they  are  not  thicker  than  the  healthy  struc- 
ture of  the  intestine  ;  the  edges  and  general  cavity  of 
an  ulcer  are  sometimes  ragged  and  at  other  times  they 
are  smooth,  as  if  a  portion  had  been  cut  out  from  the 
intestine  with  a  knife.  Sometimes  through  a  con- 
siderable length  of  the  intestine  (especially  if  it  be 
the  great  one)  the  inner  membrane  hangs  in  tattered 
shreds,  occasioned  by  the  great  ravage  of  the  ulcera- 
tion. I  have  also  seen  a  considerable  portion  of  the 
intestine  completely  stripped  of  its  inner  membrane, 
from  the  extent  of  this  process,  and  itsmuseular  coat 
appeared  as  distinct  as  if  the  inner  membrane  had 
been  very  carefully  dissected  off.  In  the  follicular 
glands,  which  are  gathered  together  in  little  oval 
groups,  I  think  ulceration  occurs  more  frequently 
than  in  the  other  parts  of  the  intestine. 

When  ulceration  advances  very  actively,  it  some- 
times eats  through  the  coats  of  the  intestine  entirely. 
When  this  is  the  case,  a  portion  of  the  contents  of  the 
intestine  occasionally  passes  into  the  general  cavity 
of  the  abdomen,  producing  inflammation  there. 
This,  however,  docs  not  very  often  happen  ;  most 
commonly  that  portion  of  the  gut  where  the  ulcer  is 
situated,  adheres  by  inflammation  to  some  other  por- 
tion, or  to  a  neighbouring  viscus,  and  a  communi- 
cation is  formed  between  the  one  and  the  other.  I 
have  seen  communications  formed  in  this  manner  be- 
tween the  rectum  and  the  bladder  in  a  male,  and  be- 
tween the  rectum  and  the  vagina  in  a  female.  I  have 
even  seen  a  communication  formed  between  the  kid- 
ney and  a  portion  of  the  intestine  from  this  cause,  by 
which  die  pus  produced  in  the  kidney  was  evacuated 


[     102     ] 

Through  the  intestine.  Such  communications  are  the 
means  of  preserving  life  (although  in  a  very  uncom- 
fortable state,)  for  a  much  longer  time  than  it  could 
be,  were  the  matter  to  pass  into  the  general  cavity 
•of  the  belly.  It  would  there  produce  peritoneal  in- 
flammation, which  would  soon  destroy.  The  inner 
membrane  of  the  intestines  is  more  disposed  to  be- 
come ulcerated,  than  the  inner  membrane  of  any  oth- 
er canal  which  has  an  external  opening.  Thus  ulcers 
are  very  rare  in  the  inner  membrane  of  the  trachea  or 
the  urethra,  but  very  common  in  the  inner  membrane 
both  of  the  great  and  the  small  intestines.  It  is  diffi- 
cult to  assign  a  satisfactory  reason  for  this  difference. 
It  probably,  however,  depends  upon  the  different 
structures  and  functions  of  these  parts.  There  is  a 
good  deal  of  resemblance  between  the  structure  of  the 
inner  membrane  of  the  trachea  and  the  urethra.  The 
secretion  of  the  one,  likewise,  is  not  very  different 
from  that  of  the  other.  The  inner  membrane  of  the 
intestines  has  a  structure  and  secretion  peculiar  to  it- 
self. It  is  probable  that  upon  these  circumstances 
depends  its  greater  disposition  to  ulcerate  ;  but  it  is 
very  difficult  to  explain  how  this  should  be  the  case. 

Inflammation  of  the  intestines  sometimes,  although 
rarely,  advances  to  mortification.  When  this  is  the 
case,  the  mortified  part  is  of  a  dark  livid  colour,  and 
has  lost  its  tenacity  ;  it  is  in  this  state  very  easily 
torn  through,  or  the  fingers  will  pass  through  it  as 
through  a  rotton  pear.  The  want  of  the  natural  tena- 
city, when  attended  with  the  change  of  colour  which 
we  have  mentioned,  is  the  only  sure  criterion  of  a 
part  being  mortified,  in  examinations  after  death. 
A  portion  of  intestine  may  be  of  a  very  dark  colour, 
and  yet  may  not  be  mortified.  This  darkness  of  col- 
our may  be  occasioned  by  a  large  quantity  of  extra v- 
asated  blood  thrown  out  during  a  high  degree  of  in- 
flammation, where  the  principle  of  life  is  maintained 
in  full  vigour.  Thus  we  see  blood,  effused  into  the 
cellular  membrane  under  the  skin,  producing  a  very 
dark  appearance,  yet  the   parts   are  quite   alive.     It 


[     103     ] 

has  often  happened,  too,  that  a  very  dark  portion  of 
intestine  has  been  returned  in  the  operation  of  the 
bubonocele,  and  yet  the  parts  have  recovered  their 
natural  functions.  This  could  never  have  happened 
if  the  black  portion  of  the  intestine  had  really  been 
mortified.  Under  such  circumstances,  the  mortified 
part  would  have  separated  from  the  living,  and  the 
function  of  the  gut  must  have  been  destroyed. 
When  a  portion  of  gut  has  been  for  some  time  morti- 
fied, a  considerable  quantity  of  air  is  formed,  which 
is  accumulated  in  its  cavity.  This  is  a  part  of  the 
natural  process  which  takes  place  in  all  dead  animal 
substances.  I  have  known  an  instance  where  a  large 
portion  of  the  great  intestine  (viz.  above  a  yard  of 
it,)  had  lost  its  living  principle,  and  was  expelled 
through  the  anus.  The  person  lived  about  three 
weeks  afterwards.* 


Lit  us-  Susceptio. 

This  is  not  a  very  uncommon  disease,  and  is  fre- 
quently fatal.  It  consists  in  a  portion  of  gut  passing 
for  some  length  within  another  portion,  and  dragging 
along  with  it  a  part  of  the  mesentery.  The  portion 
of  gut  which  is  received  into  the  other,  is  in  a  con- 
tracted state,  and  is  sometimes  of  considerable 
length.  It  usually  happens  that  an  upper  portion  of 
intestine  falls  into  a  lower;  but  the  contrary  likewise 
occurs,  although  rarely.  Intus-susccptio  may  take 
place  in  any  pari  of  the  intestinal  canal,  but  it  hap- 
pens most  frequently  in  the  small  intestines,  and 
where  the  ileum  terminates  in  the  colon.  In  this  last 
situation,  it  appears  to  me  to  happen  more  frequent- 
ly than  any  where  else.  This,  perhaps,  depends  on 
the  great  difference  in  size  between  these  two  por- 
tions of  intestine.  In  opening  bodies,  particnU 
of  infants,  an  intus-susceptio  is  not  {infrequently 
found,  which  had  been  attended  with  no  mischief  : 
the  parts  appear  perfectly   free  from  inflammation, 

•  Sec  Medical  ar.J  Chirurgicil  transactions,  Vol.  2.  p.   IK 


[     104     ] 

and  they  would  probably  have  been  easily  disentan- 
gled from  each  other  by  their  natural  peristaltic  mo- 
tion. At  other  times,  however,  so  large  a  portion 
of  the  gut  passes  within  another  portion  of  it  that  it 
cannot  be  disentangled,  which  may  produce  violent 
inflammation,  and  the  passage  of  the  intestines  is  ob- 
structed, without  any  possibility  of  its  being  set  free. 
This  is  the  fatal  state  of  the  disease. 


Ruptures. 

A  portion  of  the  viscera  of  the  abdomen  frequently 
passes  out  of  that  cavity,  being  lodged  in  a  bag  of 
elongated  peritonaeum  ;  and  this  disease  is  called  a 
rupture.  It  happens  most  commonly  from  some  sud- 
den and  violent  concussion  of  the  body,  where  the 
weaker  parts  of  the  parietes  of  the  abdomen  give 
way.  I  once  thought,  and  it  is  I  believe  the  general 
opinion,  that  ruptures  occur  more  frequently  in  fat 
than  in  lean  people  ;  but  from  some  conversation 
which  I  have  had  with  persons,  whose  line  of  life  leads 
them  to  give  particular  attention  to  this  disease,  I 
am  disposed  to  think  that  this  opinion  is  ill  founded. 
Ruptures  are  found  to  be  as  frequent  in  persons  who 
are  not  corpulent,  as  in  those  who  are.* 

There  is  hardly  any  viscus  which  has  not  at  some 
time  or  ether,  been  found  in  the  sack  of  a  rupture, 
but  most  frequently  it  is  either  a  portion  of  the 
omentum,  or  of  the  intestines,  or  of  both.  The 
bag  formed  by  the  peritonaeum  may  be  thrust  out  al- 
most at  any  part  of  the  belly  ;  but  this  happens  most 
frequently  at  the  ring  of  the  external  oblique  muscle, 
under  Paupart's  ligament,  and  at  the  navel  :  it  also 
sometimes  takes  place  at  other  parts  of  the  abdomen. 
There  is  another  situation  where  a  rupture  has  been 
known  to  happen,  although  very  rarely,  viz.  through 

*  The  umbilical  rupture  should  be  considered  as  an  exception  to  this  re- 
mark, for  it  15  much,  more  commoa  in  fat  people  than  those  of  a  spare  habit. 


[     105     1 

an  opening  in  the  diaphragm  into  the  thorax.  The 
opinion  which  would  most  obviously  be  formed  about 
this  is,  that  a  portion  of  the  diaphragm  had  burst, 
and  a  part  of  the  intestines  had  protruded  into  the 
opening  made  in  the  diaphragm.  I  am  persuaded, 
however,  that  this  opinion  will  almost  always  be  ill 
founded.  It  happens  sometimes,  but  very  seldom, 
that  children  are  born  with  a  hole  in  the  diaphragm, 
which  is  a  malformation  or  monstrosity  in  this  part 
of  the  body.  When  the  hole  is  large,  a  considerable 
portion  of  the  abdominal  viscera  passes  into  the  tho- 
rax, and  so  impedes  the  functions  of  the  heart  and 
lungs,  that  children  under  these  circumstances  perish 
immediately  after  birth.  When  the  hole  in  the  dia- 
phragm is  small,  it  lays  the  foundation  of  the  hernia 
or  rupture  which  we  have  just  described,  and  which 
may  be  called,  by  way  of  distinction,  the  diaphragm- 
atic hernia.* 

It  is  well  known  that  the  most  usual  situation  of  a 
rupture  in  the  male,  is  at  the  ring  of  the  external  ob- 
lique muscle  ;  and  this  arises  probably  from  the  lar- 
ger size  of  that  opening  in  the  male  than  in  the  fe- 
male. The  most  usual  situation  of  a  rupture  in  the 
female  is  known  also  to  be  either  under  Pau part's 
ligament,  or  at  the  navel.  The  reason  of  the  fre- 
quency of  the  first  situation,  is  the  particular  shape 
of  the  pelvis  in  the  female,  by  which  there  is  a  larger 
empty  space  under  Paupart's  ligament,  than  in  the 
male,  so  that  the  viscera  in  that  part  are  less  firmly 
supported.  The  reason  why  the  second  situation  of 
a  rupture  occurs  often  in  a  female,  is,  probably,  fre- 
quent child-bearing.  During  pregnancy,  at  its  ad- 
vanced period,  the  navel   opens,  or  gives   way,  and 

•  A  case  of.  this  kind  has  occurred  to  Dr.  Clatke,  and  has  been  publish- 
ed by  him  in  the  2d  volume  of  the  Medical  and  Ch'ntirgicnl  Tran<aciions,  p- 
US.  lie  hasbcenso  iblijjing  as  to  give  me  the  preparation  which  illustrates 
this  hernia. 

o 


[     106     ] 

where  pregnancies  have  been  frequent,  it  probably 
never  recovers  its  original  strength. 

The  omentum  is  more  commonly  found  in  the 
sack  of  a  rupture  than  any  of  the  viscera.  This  per- 
haps arises  from  its  being  a  loose  mass,  net  tied  down 
to  any  particular  situation,  and  therefore  it  readily 
passes  into  any  cavity  which  communicates  with  the 
abdomen.  When  it  has  once  fallen  down,  it  has  no 
means  of  pulling  itself  out,  like  a  portion  of  intestine, 
which  is  another  reason  why  it  is  so  often  found  in  a 
rupture.  When  it  has  remained  long  in  a  sack,  it 
forms  a  pretty  compact  mass,  sometimes  having  no 
connection  with,  but  at  other  times  adhering  to  the 
inner  surface  of  the  sack.  There  is  frequently  no  in- 
flammation produced  in  the  omentum  while  in  this 
situation,  but  occasionally  violent  inflammation  kikes 
place,  which  may  even  advance  to  mortification. 

A  portion  of  gut  is  very  often  lodged  in  the  sack 
of  a  rupture,  either  by  itself,  or  along  with  a  portion 
of  the  omentum.  The  portion  of  gut  is  sometimes 
very  small,  but  sometimes  it  is  very  considerable. 
Very  often  the  functions  of  the  intestines  go  on  prop- 
erly in  this  situation,  but  occasionally  violent  inflam- 
mation is  produced,  interrupting  their  function,  and 
often  terminating  fatally.  This  inflammation  is  pro- 
duced by  the  gut  being  strongly  pressed  at  the  nar- 
rowest part  of  the  sack,  viz.  at  that  part  where  the 
sack  immediately  passes  out  of  the  cavity  of  the  abdo- 
men. This  inflammation  exhibits  the  different  ap- 
pearances, upon  dissection,  which  we  have  so  often 
related.  The  gut  too,  is  frequently  found  mortified  : 
this  is  shewn  by  its  dark  colour,  by  its  want  of  prop- 
er tenacity,  and  by  the  air  which  is  formed  within  it. 
When  the  inflammation  of  the  gut  in  a  sack  has  not 
been  very  violent,  and  has  terminated  by  resolution, 
it  frequently  leaves  adhesions  behind  it,  connecting 
the  gut  with  the  inner  surface  of  the  sack.  It  is  per- 
haps possible  too,  that  adhesions  maybe  formed  by 
long  close  contact,  without  inflammation. 


I     107     ] 

When  the  sack  of  a  rupture  has  not  been  of  Ion?, 
standing,  it  consists  of  a  thin,  firm,  white,  opaque 
membrane  ;  this  is  a  protruded  part  of  the  periton;r 
urn,  somewhat  thickened  by  pressure.*  When  thr 
sack  has  been  of  long  standing,  it  is  often  very  thick, 
and  evidently  consists  of  a  number  of  layers.  I'm 
sack  upon  the  inside  has  a  very  smooth  surface,  and 
the  membrane  which  forms  this  surface,  can  be  read- 
ily traced  into  the  peritoneum,  lining  the  cavity  of  the 
abdomen  ;  the  outer  surface  of  the  sack  is  more- 
rough  and  coarse  in  its  texture.  The  sack,  where  it 
passes  out  of  the  cavity  of  the  abdomen,  has  frequent- 
ly a  narrow  neck,  or  aperture,  and  is  distended  be- 
low into  a  bag  of  considerable  size.  At  other  times, 
the  communication  between  the  sack  and  the  cavity 
of  the  abdomen,  is  by  a  larger  opening. 


Hernia  Congenita, 

In  bubonocele  the  sack  is  usually  quite  distinct 
from  the  sack  of  the  tunica  vaginalis  testis.  Some- 
times,  however,  there  is  no  separation  between  them, 
and  the  contents  of  the  rupture  are  immediately  in 
contact  with  the  body  of  the  testicle  :  this  kind  of 
rupture  is  called  the  hernia  congenita.  It  was  for- 
merly supposed  to  arise  from  a  portion  of  the  sack 
of  the  rupture  and  of  the  tunica  vaginalis  giving  way, 
so  that  the  contents  of  the  rupture  fell  into  the  cavity 
of  the  tunica  vaginalis  testis,  and  came  in  contact 
with  the  testicle.  Upon  a  little  reflection,  it  might 
have  been  perceived  that  this  could  hardly  take  place  ; 
though  the  true  account  of  this  appearance  was  not 
known  till  it  was  explained  by  Dr.  Hunter.  Baron 
Haller  discovered,  that  till  about  the  eighth  month  the 

•  In  some  ca«es  of  umbilical  hernia,  l)r    Marshall   has    observed  uo  dis- 
tinct appearance  of  peritonaea!  sack.    This  must  have  aris<  n  from  the  \ 
ntcum  having  burst,  in  consequence  of  distention  I   edges  be 

ing  lost  by  adlvesiou  in  the  neigh b  :uring  ■ 


[     108     ] 

testicles  do  not  descend  into  the  scrotum,  but  arc  sit- 
uated in  the   cavity  of  the  abdomen   under  the  kid- 
neys.    When  they  descend  into  the  scrotum,  the  pe- 
ritonaeum that  covers  them  is  necessarily  drawn  down 
along  with  them  through  the  ring  of  the  external  ob- 
lique muscle  ;  it  then  forms  a  bag,  the  upper  extrem- 
ity of  which  communicates  with  the  cavity  of  the  ab- 
domen.    Baron  Haller  had  also  observed,  that  in  in- 
fants a  portion  of  intestine   sometimes  falls  down  into 
this  bag  after  the  testicle,  or  along  with  it,  producing 
what  he  called  the  hernia  congenita.     The  communi- 
cation between  the  bag  and  the  abdomen  is  common- 
ly closed,  sometimes  a  little  before,  and   sometimes 
soon  after  birth.     It  appears,  however,  that  if  it  be 
prevented  from  closing  at  the  usual  time,  it  does  not 
close  afterwards   but    remains   open    through   life. 
Hence,  if  any  portion  of  an  intestine,  or  of  the  omen- 
tum, falls  into  the  elongated  sack  of  the  peritonaeum, 
it  must  be  in  contact  with   the  testicle.     When  Dr. 
Hunter  became  acquainted  with  the  observations  of 
Baron  Haller  upon  the  descent  of  the  testicles,  he  saw 
at  once  that  the  species  of  rupture  sometimes  to  be 
met  with  in  adults,  where    a  portion  of  intestine  or 
omentum  is  in  contact  with  the  testicle,  might  be  ea- 
sily explained.-     His  explanation  corresponded  with 
that  which  we  have  just  given,  and  has  been  univer- 
sally adopted  by  anatomists  and  surgeons. 


Schirrhus  and  Cancer  of  the  Intestines. 

Schirrhus  is  a  disease  which  takes  place  much  more 
commonly  in  the  great  than  in  the  small  intestines, 
but  the  latter  are  occasionally  affected  by  it.  I  have 
seen  a  schirrhus  tumour,  and  a  cancerous  ulcer  in 
the  duodenum.  In  the  great  intestines,  at  an  advan- 
ced period  of  life,  schirrhus  is  not  uncommon  :  eve- 
ry portion  of  this  intestine  is  not  equally  liable  to  be 
affected  by  it,  but  it  is  to  be  found  much  more  fre- 
quently at  the  sigmoid  flexure  of  the  colon,  or  in  the 


[     109     ] 

rectum,  than  any  where  else,  which  perhaps  may 
depend  on  the  following  circumstances.  There  is 
certainly  more  of  glandular  structure  in  the  inner 
membrane  of  the  great  intestines  towards  its  lower 
extremity,  than  in  any  other  part  of  it,  and  this  sort 
of  structure  has  a  greater  tendency  to  be  affected  with 
schirrhus,  than  the  ordinary  structures  of  the  body  : 
the  gut,  too,  is  narrower  at  the  sigmoid  flexure  than 
at  any  other  part,  and  therefore  will  be  more  liable  to 
be  injured  by  the  passage  of  hard  bodies  ;  these  by 
their  irritation,  may  excite  the  disease  of  schirrhus 
in  a  part  which  was  prc-disposcd  to  it. 

The  schirrhus  sometimes  extends  over  a  consider- 
able length  of  the  gut,  viz.  several  inches  ;  but  gen- 
erally it  is  more  circumscribed.  It  exhibits  the  same 
appearances  of  structure  which  were  described  when 
speaking  of  schirrhus  of  the  stomach.  The  perito- 
naea!, muscular,  and  internal  coats  are  much  thicker 
and  harder  than  in  a  natural  state.  The  museular  too 
is  subdivided  by  membraneous  septa,  and  the  internal 
coat  is  sometimes  formed  into  hard  irregular  folds. 
It  often  happens  that  the  surface  of  the  inner  mem- 
brane is  ulcerated,  producing  cancer.  Every  vestige 
of  the  natural  structure  is  occasionally  lost,  and  the 
gut  appears  changed  into  a  gristly  substance.  When 
schirrhus  affects  the  gut,  the  passage  at  that  part  is 
always  narrowed,  and  sometimes  so  much  so  as  to 
be  almost  entirely  obstructed.  The  obliteration,  or 
stricture,  would  sometimes  appear  to  be  greater  than 
in  proportion  to  the  thickness  of  the  sides  of  the  dis- 
eased gut :  this,  most  probably,  depends  upon  the 
contraction  of  the  muscular  fibres  of  the  gut,  which, 
although  discasd,  have  not  altogether  lost  their  natu- 
ral action.  Where  the  passage  is  very  much  obstruct- 
ed, tli  gut  is  much  enlarged  immediately  above  the 
obstruction,  from  the  accumulation  of  the  contents  in 
that  part  of  the  intestine.  While  this  disease  is  go- 
ing on  in  a  portion  of  the  intestine,  adhesions  are  for- 


[     110     ] 

meet  between  it  and  the  neighbouring  viscera,  and  the 
ulceration  sometimes   spreads  from  the   one  to  the 

other. 


The  diseased  Change  of  the  In  testifies  in  Dysentery. 

The  inner  membrane  of  the  great  istestines  I  have; 
seen  a  good  deal  thickened,  and  formed  into  small  ir- 
regular tubercles,  some  of  which  were  of  a  white, 
and  others  of  a  yellowish  colour  ;  the  peritoneal  and 
muscular  coats  were  also  thicker  and  harder  than'in  a 
natural  state.  In  some  places  too  the  inner  mem- 
brane appeared  abraded,  and  the  tubercles  were  some- 
times fissured  upon  the  surface,  so  as  to  resemble 
little  common  warts.  This  is  not  a  frequent  appear- 
ance of  disease,  but  it  has  generally  been  found  to 
take  place  in  very  severe  dysenteries,  such  as  those 
which  occasionally  arise  in  oamps.  In  the  common 
cases  of  dysentery,  which  takes  place  during  the  au- 
tumnal season  in  this  country,  the  morbid  appear- 
ance just  described  is  not  found  ;  at  least  no  instance 
of  it  has  falien  under  my  observation.  When  such 
cases  prove  fatal,  a  number  of  ulcers  are  discovered, 
by  examination  after  death,  in  the  inner  membrane 
of  the  great  and  sometimes  of  the  small  intestines. 


Thickened  Folds  of  the  Inner  Membrane  of  the  Great 
Intestines. 

I  have  also  seen  the  internal  membrane  of  the  great 
intestines  formed  into  broad  thick  folds,  in  which  a 
considerable  quantity  of  blood  was  accumulated  ; 
these  folds  were  perfectly  independent  of  the  state  of 
the  contraction  in  the  muscular  coat,  nnd  were  very 
different  in  their  appearance  from  the  irregular  puck- 
ering which  is  often  seen  in  the  inner*  membrane  of 
the  great  intestines.  When  these  folds  were  exam- 
ined, they  were  found  to  consist  of  an  accumulation 


C    hi   ] 

of  cellular  membrane,  with  the  inner  coat  of  the  gut 
reflected  over  it. 

Upon  the  inner  surface  of  the  great  intestine, 
about  two  inches  above  the  anus,  little  processes 
sometimes  grow  from  the  internal  membrane  :  they 
generally  surround  the  gut  at  short  distances  from 
each  other,  so  as  to  form  a  sort  of  circle. 


Piles. 

Piles,  and  fistulas  in  ano,  are  diseases  which  arc 
extremely  common*,  but  which  hardly  ever  become 
an  object  of  examination  after  death  ;  they  have  there- 
fore not  been  so  commonly  introduced  into  accounts 
of  morbid  appearances,  as  others  which  much  more 
rarely  occur.  Piles  are  soft  tumours  commonlv  situ- 
ated round  the  verge  of  the  anus,  sometimes  of  a  reg- 
ularly bulbous,  and  sometimes  of  an  irregular  form. 
They  arc  covered  with  a  very  tender  skin,  which 
partly  consists  of  the  fine  skin  immediately  round  the 
anus  on  the  outside,  and  partly  of  the  inner  membrane 
of  the  gut.  The  tumours  are  generally  entire,  but 
they  have  occasionally  small  openings  through  which 
a  considerable  quantity  of  blood  is  sometimes  pour- 
ed ;  they  consist  commonly  of  the  veins  round  the 
verge  of  the  anus,  much  enlarged  from  th'j  accumu- 
lation of  blood.  These  veins  arc  branches  of  the  in- 
ternal iliac  vein,  but  they  communicate  largely  with 
the  lower  branches  of  the  mesaraica  minor. 

The  same  sort  of  tumours  are  also  frequently 
found  within  the  cavity  of  the  rectum,  forming  what 
have  been  called  the  internal  piles  ;  and  these  are  oc- 
casioned by  the  enlargement  of  some  of  the  branches 
of  the  mesaraica  minor.  Piles  are  a  much  more 
frequent  disease  in  persons  who  arc  advanced  in  life, 
than  in  those  who  arc  young.  They  arise  from  re- 
peated, and  long  continued  impediments  to  the  re- 
turn of  the  blood  from  the  lower  part  of  the  rectum, 
and  there  has  been  much  more  opportunity  for  these 


[     112     ] 

impediments  to  act  in  old,  than  in  young  persons* 
They  are  also  more  common  in  women  than  in  men. 
This  may  arise  from  several  causes  :  the  uterus  du- 
ring pregnancy  must  occasion  a  great  impediment  to 
the  return  of  the  blood  from  the  rectum  :  this  is  so 
much  the  case,  that  women  who  have  been  frequent- 
ly pregnant  seldom  escape  piles.  Women  too  arc 
more  apt  to  allow  of  an  accumulation  of  the  proper 
contents  of  the  rectum,  than  men,  which  will  pro- 
duce some  impediment  to  the  return  of  the  blood  from 
this  part. 

Fistula  in  Ano. 

Fistulse  in  ano  are  narrow  canals  at  the  lower  end 
of  the  rectum,  and  are  distinguished  by  the  following 
circumstances  :  they  have  callous  edges,  a  smooth 
internal  surface,  and  possess  the  power  of  secreting 
pus.*  A  disease  of  this  sort  may  consist  of  one  ca- 
nal, opening  by  a  very  small  aperture  externally,  at 
the  side  of  the  anus ;  or  this  canal  may  be  divided  into 
several  branches.  The  canal,  besides  opening  exter- 
nally, has  very  commonly  a  small  openining  into  the 
gut  itself ;  and  sometimes  there  is  a  small  opening  in- 
to the  gut,  without  there  being  any  externally  on  the 
side  of  the  anus.  It  is  much  more  common,  howev- 
er, to  find  only  an  external  opening  of  the  canal  ;  or, 
to  find  both  an  external  opening,  and  another  into  the 
gut. 

The  Rectum  terminating  in  a  Cul-de-sac. 

It  is  a  species  of  monstrous  formation,  not  very 
uncommon,  that  the  rectum  does  not  terminate  in  the 
anus,  but  in  a  cul-de-sac,  without  reaching  the  exter- 

•  Mr  Hunter  has  observed,  in  his  Lectures  on  Surgery,  that  fistulas  have 
a  sinooih  imerna.1  surface,  like  a  secreting  surface,  as,  fcr  instance,  the 
urethra. 


r  us  ] 

nal  surface.  Sometimes  the  extremity  of  the  gut 
lies  near  the  external  surface,  but  more  commonly  it 
is  at  some  distance  from  it.  In  these  cases  there  is 
usually  the  appearance  of  an  anus,  but  the  opening  is 
more  contracted  than  in  the  natural  structure.  It  sel- 
dom happens  that  this  malformation  can  be  effectu- 
ally remedied  by  a  chirurgical  operation.  The  op- 
ening which  is  made  into  the  extremity  of  the  gut  has 
generally  such  a  disposition  to  close,  that  the  benefit 
which  might  naturally  be  expected  from  an  operation 
is  frustrated.  A  few  cases  however  have  occurred 
jn  which  the  operation  has  been  successful. 


The  Rectum  terminating  in  the  Bladder. 

I  have  also  seen  the  rectum  terminate  in  the  bladder 
from  an  original  error  in  the  formation,  so  that  there 
was  no  other  external  opening  to  the  rectum  than  by 
the  urethra  :  this  was  in  a  child  at  birth  :  the  malformr 
ation  was  of  such  a  kind,  as  neither  to  admit  of  a  rem* 
cdy  by  art,    nor  to  allow  of  life  being  continued. 

The  rectum  has  also  been  known  to  terminate  in 
the  vagina,  from  a  defect  in  the  original  formation  ; 
but  this  is  very  uncommon, 

JForm$. 

Worms  are  formed  in  the  intestines  of  man,  as 
well  as  of  many  other  classes  of  animals  ;  but  not  so 
frequently  in  the  former  as  in  the  latter.  In  most 
quadrupeds  and  fishes  it  is  extremely  common  to  find 
a  number  of  worms  upon  opening  their  intestines. 

The  worms  which  are  found  in  the  human  subject, 
may  be  reduced  to  three  general  classes,  viz,  this 
lunibricus  teres  ;  taenia  ;  and  ascaris. 


L    "*   J 


Lumbricus  Teres. 

The  lumbricus  teres,  or  round  worm,    is  mticfe 
more  commonly  found  in  the  intestines  of  children, 
than  in    those  of  persons  full  grown,  or  advanced  in 
life  :  it   is  very  usually  met   with   in  the   first,  but 
rarely   in    the    two   last.     The  lumbricus   teres   is 
known  to  differ  from  the  common    earth  worm,  but 
practitioners  in  this  country   have  made  little  inqui- 
ry into  the  circumstances  upon  which  this  difference 
depends.     The  two  species  of  worms,  if  attentively 
examined,  will  be  found  to  differ  a  good   deal  from 
each  other  in  their  external  appearance.  The  lumbri- 
cus teres  is  more  pointed  at  both   extremities,  than 
the  common  earth  worm.    The  mouth  of  the  lumbri- 
cus teres  consists  of  three  rounded  projections,  with 
an  intermediate  cavity  j  the  mouth  of  the  earth  worm 
consists  of  a  small  longitudinal   fissure,  situated  on 
the  under  surface  of  a  small  rounded  head.     Upon 
the  under  surface  too  of  this  worm  there  is  large  sem- 
ilunar fold  of  skin,  into  which  the  head  retreats,  or 
out  of  which  it  is  elongated,  which  is  entirely  want- 
ing in  the  kimbricus  teres.     The  anus  of  the  lumbri- 
cus teres  opens  upon  the  under  surface  of  the  worm f 
a  little  way  from  its  posterior  extremity,  by  a  trans- 
verse curved  fissure  ;  the   anus   of  the  earth  worm 
opens  by  an  oval  aperture  at  the    very  extremity  of 
the  worm.  The  outer  covering  or  skin  in  the  lumbri- 
cus teres  is  less  fleshy,  and  less   strongly  marked  by 
transverse  ruga?,  than  in  the  earth  worm.     In  the  lat- 
ter there  is  often  to  be  seen  a  broad   yellowish  band,. 
surrounding  the  body  of  the  worm  ;  but  in  the  lum- 
bricus teres,  this  is  entirely  wanting.     On  each  side 
of  the  lumbricus  teres  there  is  a  longitudinal  line  very 
well  marked  ;  in  the  earth  worm  there  are  three  lon- 
gitudinal lines  upon  the  upper  half  of  its  surface,  but 
these  are  so  faintly  marked,  as  to  be  hardly  observa- 
ble.    The  lumbricus  teres  has  nothing  corresponding 


[     115     ] 

to  feet,  whereas  the  earth  worm  has  on  its  under  sur- 
face, but  more  strongly  marked  towards  its  posterior 
extremity*  a  quadruple  row  of  processes  on  each  side, 
very  sensible  both  to  the  eye,  and  the  finger,  which 
manifestly  serve  the  purposes  of  feet  in  the  locomo- 
tion of  the  animal. 

The  internal    structure  of  these   two   species  of 
worms  is  also  extremely  different.     In  the  lumbricus 
teres,  there  is  an  intestinal  canal,  nearly  uniform  and 
smooth  in  its  ?4ppearancc,  which  passes  from  one  ex- 
tremity of  the  worm  to  the  other.     Near    the  head  of 
this  worm,  the  canal  is  narrower  than  it  is  any  where 
else,  and  somewhat  distinct   in  its  limits  :   this  may 
be  considered  as  the  oesophagus.     In  the  earth  worm 
there  is  a  large  and  complex    stomach,  consisting  of 
two  cavities  ;  and  the  intestinal  canal   in  the  latter  is 
likewise  larger,  and  more  formed  into  sacculi,  than 
the  former.     Th«  parts  subservient    to  generation  in 
these  two  species  of  worms   differ  very  much   from 
each  other  ;  in  the  lumbricus  teres  there  is  a  distinc- 
tion of  sex,  the  parts  of  generation  being  different  in 
the  male  and  in  the   female  ;   in   the    common  earth 
worm  the  organs  of  generation  are  the  same    in  each 
individual,  as  this  worm  is  hermaphrodite.     The  ap- 
pearance too  of  the  organs  of  generation,  is  extreme- 
ly different  at  first  sight  in  the  one  species  of  animal, 
and  the  other.     There  is  an  oval  mass  situated  at  the 
anterior  extremity  of  the  earth  worm,  resembling  a 
good  deal  the  medullary  matter  of  the  brain  ;  in   the 
lumbricus  teres  this  substance  is  wanting.*     These 
are  the  principal  differences   between  the  one  species 
of  animal  and  the  other,  which   am  obvious    upon  a 
very  moderate  attention  to  each.      Many  other  differ- 
ences would,  doubtless,   be  found  by  a  person  who 
might  choose  to  prosecute  their  anatomy  minutely. 

*  What  this  substance  is  I  do  not  know,  aiul  I  have  only  mentioned  its  re- 
semblance to  the  medullary  matter  of  the  braia,  v.\  order  to  give  a  clearer  des- 
cription oi'i'. 


£     "4    ] 


T tenia. 

The  taenia  which  is  most  commonly  found  in  the 
human  intestines,  is  of  two  kinds,  viz.  the  taenia 
solium.,  and  the  taenia  lata* 

Tcenia   Solium. 

This  taenia  is  frequently  bred  in  the  intestines  of 
the  inhabitants  of  Germany,  and  occasionally,  but 
rarely,  in  those  of  the  inhabitants  of  Great  Britain* 
It  consists  of  a  great  many  distinct  portions,  which 
are  connected  together  so  as  to  put  on  a  jointed  ap* 
pearance  ;  these  joints  are  commonly  of  a  very  white 
colour,  but  are  occasionally  brownish,  which  depends 
on  a  fluid  of  this  colour  that  is  found  in  their  vessels* 
The  worm  is  usually  very  long,  extending  often  ma- 
ny yards,  and  seldom  passes  entire  from  the  bowels* 
This  circumstance  has  prevented  the  extremities  of 
the  tLenia  from  being  often  seen. 

The  head  of  this  taenia  is  somewhat  of  a  square  form, 
with  a  narrowed  projection  forwards  ;  in  the  middle 
cf  this  projecting  part,  there  is  a  distinct  circular  a- 
perture,  around  the  edge  of  which  grow  curved 
sharp  processes.  Near  the  angles  of  the  square  edge 
of  the  head,  are  situated  four  round  projecting  aper- 
tures, at  equal  distances  from  each  other  :  this  head 
is  placed  upon  a  narrow  jointed  portion  of  the  worm, 
of  considerable  length,  and  which  gradually  spreads 
itself  into  the  broader  joints,  of  which  the  body  of  the 
Worm  is  composed. 

The  body  of  the  taenia  consists  of  thin,  flat,  pretty 
long  joints,  on  one  edge  of  which  there  is  a  projec- 
tion, with  a  very  obvious  aperture.  In  the  same 
worm  some  of  these  joints  appear  considerably  longer 
than  others-,  which  probably  depends  on  one  joint  be» 
ing  contracted,  while  another  is  relaxed.     The  aper* 


[     117    1 

tnres  which  we  have  just  mentioned  are  generally  pla- 
ced on  the  opposite  edges  of  the  contiguous  joints  ; 
but  this  is  not  uniformly  the  case  ;  they  are  some- 
times placed  on  the  same  edges  of  twro,  or  even  sev- 
eral contiguous  joints.  When  these  joints  are  ex- 
amined attentively,  there  are  frequently  seen,  in  each 
of  them,  vessels  filled  with  a  brownish  fluid,  and  dis- 
posed in  an  arborescent  form.  Around  the  edges  of 
each  joint,  there  is  also  a  distinct  serpentine  canal.* 
The  last  joint  of  a  taenia  resembles  very  much  a  com- 
mon joint  rounded  off  at  its  extremity,  and  without 
any  aperture. 

Tania  Lata. 

The  tenia  lata  is  bred  very  commonly  in  the  intes- 
tines of  the  inhabitants  of  Switzerland,  but  very  rare- 
ly in  those  of  the  inhabitants  of  Great  Britain.  The 
joints  of  which  it  is  composed  are  short  and  broad, 
snd  the  aperture  is  not  upon  the  edge  of  each  joint, 
as  in  the  solium,  but  in  the  middle  of  its  flattened  sur- 
face. Round  these  apertures  are  short,  radiated 
vessels.  The  head  is  of  an  oval  shape,  and  so  small 
that  its  minute  structure  is  not  visible  by  the  naked 
eye.  Its  tail  terminates  in  two  narrow  processes,  one 
of  which  is  longer  than  the  other. 

Other  taenia   have  occasionally  "been  found  in  the 

human  intestines,   but   they    occur  very   rarely,  and 

have  not  fallen  under  my  own  observation. 
i 

Ascaris. 

The  ascaris  is  a  very  small  worm,  which  is  often 
found  at  the  lower  end  of  the  rectum  in  children,  and 
even  more  frequently  in  adults  than  is  commonly  im- 

"  This,  as  well  as  the  vessels  disposed  in  an  arborerccnt  form,  is  very  dis. 
trnctly  seen  injected  in  some  preparations  which  have  been  uiaJe,  and  given 
to  me  by  an  ingenious  iwgeoa,  Mr.  Carlisle. 


C     118     ] 

agined.  It  is  white  in  its  colour,  and  about  half  an 
inch  in  length  ;  at  the  extremity  where  its  head  is 
plactd,  it  is  a  little  narrowed,  and  at  the  other  ex- 
tremity it  terminates  in  a  long,  very  fine,  transparent 
process.  These  worms  are  more  or  less  surrounded 
with  mucus,  which  is  secreted  in  increased  quantity 
by  the  glands  in  the  inner  membrane  of  the  rectum, 
from  the  irritation  occasioned  by  the  worms. 

Trichuris. 

This  worm  has  been  occasionally  found  in  the 
great  intestines  of  man,  and  more  especially  the  cce- 
cum.  It  resembles  a  good  deal  the  ascaris,  but  is 
considerably  larger,  and  has  a  very  long  transparent 
tail.  To  their  heads  is  attached  a  process  or  horn, 
which  they  can  protrude  or  retract. 

There  is  nothing  in  the  economy  of  animals  more 
obscure  than  the  origin  of  intestinal  worms  ;  were 
they  found  to  live  out  of  the  bodies  of  living  animals, 
one  might  readily  suppose  that  their  ovula  were  taken 
into  the  body  along  with  the  food  and  drink,  and  there 
gradually  evolved  into  animals.  This,  however,  is 
not  the  case  ;  they  do  not  seem  capable  of  living  for 
any  length  of  time  in  any  situation,  except  within  a 
living  animal  body,  which  appears  to  be  the  proper 
place  for  their  growth  and  residence.  We  might 
therefore  be  led  to  another  supposition,  viz.  that 
intestinal  worms  are  really  formed  from  the  matter 
contained  in  the  intestines,  which  previously  had  no 
regular  organization  ;  but  this  idea  is  widely  differ- 
ent from  all  analogy  in  the  production  of  animals, 
where  there  has  been  any  satisfactory  opportunity  of 
examining  this  production.  The  origin,  therefore, 
of  such  animals  is  a  subject  of  much  obscurity,  and 
probably  will  not  have  soon  any  satisfactory  light 
thrown  upon  it. 


C     119     1 


Air  accumulated  in  the  Intestines, 

It  is  not  unusual  to  find  air  accumulated  in  the  in- 
testinal canal,  in  greater  or  less  quantity  ;  this  air  is 
sometimes,  but  not  constantly,  accompanied  with  a 
slight  inflammation  of  the  peritoneum.  In  such  ca- 
ses the  blood  vessels,  creeping  upon  the  intestines, 
are  sometimes  filled  with  air,  but  frequently  they  are 
without  it.  Air  is  often  let  loose  into  the  intestines 
after  death  by  putrefaction  :  but  that  which  we  wish 
particularly  to  consider  here,  has  been  formed  during 
life. 

There  are  only  two  ways  in  which  we  can  well 
conceive  air  to  be  formed  in  the  intestines  :  the  one 
is,  some  new  arrangement  in  the  contents  of  the  in- 
testines, by  which  air  is  cxtricajted  :  the  other  is,  the 
formation  of  air  in  the  blood  vessels  of  the  intestines 
by  a  process  similar  to  secretion,  and  which  air  is  af- 
terwards poured  out  by  the  extremities  of  the  exha- 
lant  arteries  into  the  cavity  of  the  intestines.  That 
the  blood  vessels  of  an  animal  body  have  this  power 
there  can  be  no  doubt ;  and  I  own  I  am  inclined  to 
think  that  this  is  a  mode  not  unfrequent  by  which  air 
is  accumulated  in  the  intestines.  This  air  probably 
differs  somewhat  at  different  times  ;  in  several  trials 
which  I  have  made,  it  never  shewed  signs  of  contain- 
ing any  proportion  of  inflammable  air,  but  always  a 
.  very  sensible  proportion  of  fixed  air.  It  requires, 
however,  to  be  examined  by  some  person  well  ac- 
quainted with  chemical  experiments,  in  order  that  its 
ingredients  may  be  exactly  ascertained. 

Bony  Matter  formed  in  the  Intestines. 

These  are  the  most  common  appearances  of  diseas- 
ed, or  preternatural  structure  in  the  intestines  •  but 
I  have  likewise  had  an  opportunity  of  observing  oth- 


[     120     ] 

ers,  which  are  of  rarer  occurrence.  In  one  or  two 
instances  I  have  seen  a  scrt  of  bony  matter  thrown 
out  upon  the  surface  of  the  inner  membrane  of  the 
gut  :  I  have  even  seen  an  adhesion  between  two  por- 
tions of  intestine,  converted  into  bone.  It  would 
appear,  that  almost  every  part  of  the  body  is  occasion- 
allv  subject  to  this  process.  It  may  not  improperly 
be" considered,  as  a  natural  process  misplaced.  An  ad- 
hesion being  once  formed,  has  the  same  power  (as  far 
as  we  know)  of  running  into  different  processes,  as  the 
cellular  membrane,  which  makes  a  part  of  the  original 
structure.  It  may  therefore  form  bone,  as  readily  as 
cellular  membrane,  or  some  other  membranes  of  the 
body,  which  have  a  resemblance  to  the  membrane  of 
adhesions,  as  the  pleura  and  the  peritonaeum. 

Projecting  Ring  formed  in  the  Cavity  of  Jejunum, 

I  have  seen  one  of  the  valvule  conniventes  much 
larger  than  usual,  and  passing  round  on  the  inside  of 
the  jejunum,  like  a  broad  ring.  The  canal  of  the  gut 
was  necessarily  much  narrowed  at  this  ring,  but  no 
mischief  had  arisen  from  it.  This  malformation,  how- 
ever, might  have  laid  the  foundation  of  fatal  mischief. 
Some  substance,  too  large  to  pass,  might  have  rested 
on  the  ring,  and  produced  there  inflammation,  ulcer* 
ation,  and  ultimately  death. 


Calculous  Matter  in  the  Intestines. 

Calculous  matter  has  sometimes  been  known  to  be 
accumulated  in  some  part  of  the  cavity  of  the  intesti- 
nal canal,  especially  in  the  great  intestine  ;  but  this 
has  not  come  under  my  own  observation,  and,  at 
least  in  the  human  subject,  is  a  very  rare  occurrence.* 

•  Vid.  Lieu  laud,  Tom.  1,  p.  TT,  78. 


[     121     ] 


Small-pox  Pustules  said  to  be  in  the  Intestines. 

Small-pox  pustules  have  been  said  to  be  some- 
times found  in  the  intestines  of  persons  who  had  died 
from  this  disease.*  How  far  this  may  have  occasion- 
ally taken  place,  I  will  not  pretend  to  say,  but  late  dis- 
sections, upon  the  best  authority,  have  not  confirmed 
this  fact. 


Diseased  Appearances  of  the  Mese  n  tcrij.  — Mesentery 

inflamed. 

The  mesentery  is  often  found  in  a  state  of  inflam- 
mation ;  although  I  believe  this  hardly  ever  takes 
place,  unlesswhenthe  peritonaeum  generally  is  inflam- 
ed. When  the  mesentery  is  inflamed,  it  becomes 
much  thicker,  and  more  massy,  than  in  its  natural 
state  ;  the  large  blood  vessels  which  pass  between  its 
laminae  and  the  absorbent  glands,  are  also  very  much 
obscured.  These  different  appearances  depend  upon 
the  quantityof  the  coagulable  lymph  which  is  thrown 
out,  during  the  inflammatory  action.  The  peritonaeum 
which  forms  the  laminae  of  the  mesentery  is  crowded 
with  small  blood  vessels,  and  is  covered  more  or  less 
with  a  layer  of  the  coagulable  lymph.  A  small  quan- 
tity of  pus  is  sometimes  found  on  the  surface  of  the 
inflamed  mesentery,  and  even  abscesses  have  been 
observed  between  its  laminae,  but  this  last  appearance 
is  very  rare. 

It  very  seldom  happens,  that  the  mesentery  is  found 
gangrenous,  unless  different  portions  of  the  intestin- 
al canal  be  found  in  the  same  state.  When  the  intes- 
tines are  mortified,  portions  of  the  mesentery  are 
sometimes  found  in  the  same  condition.  The  appear- 
ances exhibited  in  mortification  are  the  same  when  it 

•  Vid.  Licutaud,  Tom.  1.  p.  371. 


E     122     ] 

affects  the  mesentery,  as  in  any  other  part,  and  they 
have  been. already  described. 

Mesenteric  Glands  scrofulous. 

The  absorbent  glands  of  the  mesentery,  are  fre^ 
quently  found  to  be  scrofulous,  and  this  is  more  apt 
to  take  place  in  children^  than  in  persons  of  a  more 
advanced  age.  When  affected  with  this  disease,  the 
glands  exhibit  different  appearances,  according  to  its 
progress  :  they  are  enlarged  in  their  size,  and  are 
somewhat  softer  to  the  touch,  than  in  a  natural  state. 
When  cut  into,  they  sometimes  shew  very  much  the 
natural  structure  ;  but  more  frequently  they  are  chan- 
ged, in  part,  into  a  white,  soft,  curdly  matter ;  and 
this  is  not  uncommonly  mixed  with  pus. 

Mesenteric  Glands  cancerous. 

When  a  portion  of  the  intestinal  canal  becomes 
cancerous,  some  of  the  absorbent  glands  in  the  mes- 
entery generally  become  affected  with  the  same  dis- 
ease :  this  is  in  consequence  of  the  matter  of  cancer 
being  conveyed  to  those  glands  by  absorbent  vessels. 
The  glands  become  enlarged  in  size,  and  are  chan- 
ged into  hard  masses  exhibiting  a  schirrhus,  or  a  can- 
cerous structure. 


Mesenteric  Glands  earth?/  or  bony. 

The  absorbent  glands  of  the  mesentery  arc  some- 
times filled  with  an  earthy,  or  bony  matter  ;  but  this 
is  to  be  considered  as  a  rare  occurrence.*  The  ab- 
sorbent glands  at  the  root  of  die  lungs,  are  more  lia- 
ble to  be  affected  with  this  disease. 

•  ViU.  Med.  Transactions,  Vol.  1.  p.  361. 


[     123     ] 


Hydatids  have  also  been  occasionally  found  adher- 
ing to  the  mesentery. 


Tumours,  likewise,  consisting  of  a  fatty  matter, 
have  been  seen  attached  to  the  mesentery  ;  but  these 
I  believe  to  be  very  uncommon. 


SYMPTOMS. 


Inflammation  of  the  intestines  is  characterised  by 
the  following  symptoms,  viz.  an  acute  pain  in  the 
-abdomen,  vomiting,  obstinate  costiveness,  sympto- 
matic fever,  with  a  frequent  small  and  hard  pulse. 
The  pulse,  however,  is  sometimes  less  affected  than 
might  have  been  supposed.,  from  the  violence  of  the 
inflammation. 


The  symptoms  attending  intus-susceptio  are  simi- 
lar to  those  which  belong  to  inflammation  of  the  in- 
testines, and  indeed  this  disease  is  not  unfrequently 
accompanied  with  inflammation.  It  is  however  more 
likely  to  prove  fatal  than  simple  inflammation  of  the 
bowels,  as  it  does  not  admit  of  any  substantial  bene- 
fit from  medicine. 


L    124   ] 


When  there  is  a  rupture  without  any  strangula- 
tion of  the  intestine,  the  following  symptoms  take 
place,  viz.  a  pale  swelling  at  the  part  affected,  a  slight 
pain  occasionally  felt  in  the  swelling  itself,  and 
spread  somewhat  over  the  region  of  the  belly,  the 
swelling  pushed  out  by  coughing,  a  disappearance 
of  the  swelling  upon  pressure,  or  upon  the  person 
continuing  for  a  considerable  length  of  time  in  a  hor* 
izontal  posture.  When  a  rupture  is  large  and  of  long 
standing,  it  will  often  be  incapable  of  being  reduced 
by  pressure,  even  when  there  is  no  strangulation. 

When  strangulation  takes  place,  the  same  symp- 
toms arise  which  belong  to  inflammation  of  the  bow- 
els, for  the  strangulation  produces  inflammation. 
These  consist  of  a  pain  in  the  swelling,  which  is  dif- 
fused over  the  abdomen,  sickness,  vomiting,  obstin- 
ate costiveness,  heat,  commonly  a  frequent,  small, 
and  a  hard  pulse  :  and  towards  the  fatal  conclusion  of 
thedisesse  there  is  hickup,  with  a  foetid  yellow  mat- 
ter thrown  out  by  the  mouth.  The  sickness  I  have 
heard  described,  as  being  infinitely  more  distressing 
than  the  ordinary  sickness  of  a  deranged  stomach  ; 
the  pulse  is  sometimes,  in  such  a  case,  not  increased 
in  frequencv  beyond  the  standard  of  health  ;  and  yet 
the  inflammation  of  the  bowel  has  been  discovered  af- 
terwards by  the  operation  to  be  very  great.  This  is 
an  important  practical  observation,  because  it  shews 
that  the  degree  of  inflammation  is  not  to  be  judged  of 
from  the  pulse,  and  teaches  that  the  operation  should 
not  be  delayed,  after  the  proper  efforts  for  reducing 
the  rupture  have  failed,  because  the  pulse  may  hap- 
pen to  be  little  or  not  at  all  accelerated. 


When  the  great  intestine  is  attacked  with  schir- 
vhus,  the  disease  has  commonly  made  some  progress, 
before  it  is  much  attended  to   by  the   patient.     At 


[     125     ] 

first  there  is  but  little  pain  in  the  part  affected,  and  the 
patient  only  observes  that  he  is  costive,  or  that  the 
stools  pass  with  some  difficulty.  When  the  disease 
is  more  advanced,  a  considerable  pain  is  felt,  more 
especially  in  passing  a  stool,  and  there  are  occasional 
sympathetic  pains  about  the  os  sacrum  and  hips. 
When  the  stools  are  examined,  they  are  commonly 
found  to  be  narrow,  to  be  more  or  less  flattened,  and 
they  are  sometimes  besmeared  with  mucus,  pus, 
and  blood.  The  pulse  at  the  beginning  of  this  dis- 
ease is  natural,  but  towards  its  close  becomes  accel- 
erated. In  advanced  stages  of  the  disease,  the  coun- 
tenance is  sallow,  the  strength  is  much  impaired,  the 
body  is  much  emaciated,  and  the  constitution  at  length 
altogether  sinks. 


In  dysentery,  griping  pains  are  felt  in  the  abdo- 
men, which  often  arise  to  a  considerable  degree  of 
severity.  The  bowels  are  irritated  to  frequent  evac- 
uation, and  generally  discharge  mucus  tinged  with 
blood,  but  sometimes  white  lumps,  membranous 
films,  pus,  and  at  intervals  scybala.  Tenesmus  ac- 
companies the  evacuation  of  the  bowels  •,  and  there  is 
more  or  less  of  fever  connected  with  this  complaint. 


The  symptoms  attending  piles  arc  swellings  at  the 
verge  of  the  anus,  or  in  the  rectum  immediately  above 
it,  pain  felt  at  the  anus  dining  the  passage  of  the  fec- 
ces,  frequently  an  evacuation  of  blood,  and  occasion- 
al feelings  of  irritation  in  the  parts  affected.  This 
disease  is  often  preceded  by  other  affections,  such  as 
giddiness  of  the  head,  difficulty  of  breathing,  colicky 
pains,  and  pains  i:i  the  loins. 


The  symptoms  which   attend   the   round  worm  of 
the  intestines  are  a  swelled  belly,  emaciated  extrenri- 


[     126     ] 

ties,  an  offensive  breath,  and  a  deranged  appetite. 
The  appetite  is  often  greater  than  in  health,  but  some- 
times it  is  much  less.  The  stools  are  slimy  ;  and  the 
patient  frequently  picks  his  nose,  and  during  sleep 
grinds  his  teeth. 


Persons  afflicted  with  the  taenia,  complain  of  a 
gnawing  uneasy  feeling  in  the  region  of  the  stomach, 
■which  is  removed,  or  diminished  by  eating.  Their 
appetite  is  commonly  somewhat  voracious,  but  occa- 
sionally it  is  less  than  natural.  They  have  common- 
ly'an  itching  at  the  nose,  often  nausea,  colicky  pains, 
and  sometimes  giddiness.  Some  have  a  cough,  and 
others  occasional  convulsions. 


When  ascarides  are  lodged  in  the  rectum,  there  is 
an  uneasy  feeling  there,  and  a  violent  itching  at  the 
anus.  There  is  also  a  sense  of  heat  in  the  parts,  with 
occasional  tenemus  and  mocous  stools.  The  mucus 
is  sometimes  mixed  with  blood,  and  along  with  it 
some  living  ascarides  are  often  discharged.* 


When  air  is  accumulated  in  a  moderate  quantity  in 
the  bowels,  it  is  known  to  exist  by  some  fullness  of 
the  abdomen,  and  by  the  air  shifting  frequently  its 
situation.  This  is  sometimes  attended  with  a  kind  of 
gurgling  noise,  and  forms  swellings  in  particular  parts 
of  the  belly.  A  quantity  of  air  is  sometimes  expel- 
led by  the  mouth  and  the  rectum.  There  is  general- 
ly at  the  same  time  costiveness,  and  occasional  col- 
icky pains. 

When  air  is  accumulated  in  very  large  quantity, 
then  it  forms  a  very  serious  disease  called  tympanitis. 
Of  this  I  have  seen  two  or  three  instances.     The  bel- 

•  See  Med.  Trans,  of  the  College,  Vol.  1.  p.  46. 


[     127     1 

ly  is  extremely  swelled,  with  a  very  tense  feeling,  and 
there  is  a  quick  reaction  of  the  parts  after  removing 
the  pressure  of  the  fingers  from  the  belly,  exactly 
similar  to  what  takes  place  in  a  common  ox's  blad- 
der, distended  with  air.  This  circumstance  serves 
as  one  of  the  marks  of  distinction  between  tympanitis 
and  ascites.  There  is  no  sense  of  fluctuation  in  tym- 
panitis, but  in  ascites  this  is  commonly  distinct. 
There  is  often  difficulty  of  breathing,  which  is  pro- 
duced by  the  accumulation  of  the  air  pushing  up  the 
diaphragm,  and  impeding  its  free  motion.  There 
are  severe  colicky  pains,  and  quantities  of  air  are  fre- 
quently expelled  both  upwards  and  downwards  with 
a  loud  noise.  The  bowels  are  costive,  and  there  is  a 
difficulty  in  making  water,  which  is  probably  occa- 
sioned by  the  accumulation  of  air  in  the  rectum. 


The  symptoms  of  an  inflamed  mesentery  cannot  be 
separated  from  those  which  belong  to  inflammation  of 
the  peritonaeum  generally  ;  and  these  symptoms  have 
been  already  described. 


The  symptoms  which  attend  the  enlargement  of  the 
mesenteric  glands  from  scrofula  correspond  very 
much,  in  the  most  striking  circumstances,  with  the 
symptoms  which  are  produced  by  the  common  round 
worm  of  the  intestines  In  both  diseases  there  is  a 
tumid  belly,  and  emaciated  extremities.  They  are 
chiefly  to  be  distinguished  by  worms  not  being  dis- 
covered in  the  one  disease,  notwithstanding  the  use 
of  strong  purgatives,  while  they  pass  off  from  the 
bowels  in  the  other.  The  starlings,  and  the  grinding 
of  the  teeth,  may  peshaps  also  form  some  ground  of 
distinction  between  the  two  diseases  :  they  occur  very 
commonly  in  worms,  but  I  believe  rarely  where  th« 
glands  of  the  mesentery  are  scrofulous.  Some  dis- 
crimination likewise  between  the  two  diseases,  may 


[     128     ] 

sometimes  be  derived  from  examining  strictly  into  the 
nature  of  the  constitution.  If  decided  marks  of  scrof- 
ula shew  themselves  in  an  external  part  of  the  body, 
they  will  lead  a  practitioner  more  satisfactorily  to  the 
opinion,  that  the  mesenteric  glands  are  also  affected 
with  the  same  disease. 


[     129     ] 


CHAP.  IX. 


DISEASED    APPEARANCES    OF    THE    LIVIR. 


Inflammation  of  the  Membrane  of  the  Liver. 


JL  HE  external  membrane  of  the  liver  is  not  un- 
commonly found  in  a  state  of  inflammation. 

This  may  take  place  when  the  peritonaeum  gener- 
ally over  the  cavity  of  the  abdomen  is  inflamed,  or 
the  inflammation  may  be  confined  to  the  membrane 
of  the  liver  itself.  When  it  is  confined  to  the  mem- 
brane of  the  liver,  it  is  not  frequently  extended  over 
the  whole  of  it,  but  more  commonly  takes  place  in 
that  part  which  covers  the  anterior,  or  convex  part  of 
the  liver.  I  have  also  seen  inflammation,  or  at  least 
its  effects,  not  unfrequently  on  that  side  of  the  liver, 
which  is  in  contact  with  the  stomach  and  the  duo- 
denum. 

When  inflammation  takes  place  in  the  membrane 
of  the  liver,  it  exhibits  exactly  the  same  appearances, 
which  have  been  described  when  speaking  of  the  in- 
flammation of  the  peritonaeum,  of  which  it  is  a  part. 
It  is  crowded  with  a  great  number  of  very  minute  ves- 
sels, which  contain  florid  blood,  and  is  thicker  than 
in  its  natural  state.  There  is  also  thrown  out  upon 
its  surface,  a  layer  of  coagulable  lymph  ;  this  layer  is 
thicker  on  some  occasions  than  others,  and  often  glues 
the  liver,  more  or  less  completely  to  the  neighboring 

R 


[     130     ] 

parts.     Some  quantity  of  serous  fluid  is  at  the  samcr 
time  thrown  out. 


Adhesions. 

It  is  more  common  to  see  adhesions  formed,  which 
are  the  consequence  of  a  previous  inflammation  in  the 
membrane  of  the  liver,  than  to  see  the  membrane  in 
an  actual  state. of  inflammation.  These  adhesions  are 
formed  from  the  coagulable  lymph,  of  the  blood,  which 
undergoes  a  gradual  progress  of  change,  as  we  have 
formerly  described.  They  consist  very  commonly  of 
a  thin,  transparent  membrane,  which  joins  the  surface 
of  the  liver  to  the  neighbouring  parts.  This  junction 
may  either  be  general,  over  one  extended  surface  of 
the  liver,  or  it  may  consist  of  a  number  of  processes 
cf  adhesion  :  the  adhesion  is  sometimes  by  a  mem- 
brane of  considerable  length  ;  and  sometimes  the 
adhesion  is  very  close,  the  surface  of  the  liver  being 
immediately  applied  to  the  neighbouring  parts.  The 
surface  of  the  liver,  where  these  adhesions  are  most 
commonly  found,  is  the  anterior,  by  which  it  is  join- 
ed to  the  peritonaeum  lining  the  muscles  at  the  upper 
part  of  the  cavity  of  the  abdomen. 

When  an  abscess  is  formed  in  the  substance  of  the 
liver,  and  points  externally,  these  adhesions  arc  of 
great  use  in  preventing  the  pus  from  escaping  into  the 
general  cavity  of  the  abdomen.  Adhesions  are  also 
frequently  found  connecting  the  posterior  surface  of 
the  liver  to  the  stomach,  and  the  duodenum  ;  and 
these  may  also  be  useful  in  abscesses  of  the  liver, 
near  its  posterior  surface,  by  preventing  the  matter 
from  passing  into  the  general  cavity  of  the  abdomen, 
and  conducting  it  either  into  the  stomach,  or  the  up- 
l  cr  part  cf  the  intestinal  canal. 


[     131     ] 


Coats  of  t/ie  Liver  converted  into  Cartilage. 

A  part  of  the  coats  of  the  liver  is  sometimes  chan- 
ged into  cartilage.  Of  this  I  have  seen  a  few  instan- 
ces ;  but  it  occurs  much  more  rarely  in  the  liver  than 
in  the  spleen.  The  cartilage  is  smooth  and  thin,  and 
very  soft  in  its  texture. 

Inflammation  ef  the  Substance  of  the  Liver. 

It  do^s  not  often  happen,  in  this  country,  that  the 
substance  of  the  liver  is  found  in  an  actual  state  of  in- 
flammation. Where  its  membrane  is  inflamed,  the 
substance  is  sometimes  inflamed  which  lies  immedi- 
ately under  it  ;  but  it  rarely  happens  that  the  general 
mass  of  the  liver  is  inflamed.  In  warmer  countries, 
the  substance  of  the  liver  is  much  more  liable  to  in- 
flammation than  in  Great  Britain.  When  the  liver  is 
generally  inflamed  through  its  substance,  it  is  a  good 
deal  enlarged  in  size,  and  of  a  purple  colour.*  It  is 
also  harder  to  the  touch,  than  in  its  healthy  state.  Its 
outer  membrane  is  sometimes  affected  by  the  inflam- 
mation, and  sometimes  it  is  not.  It  is  attended  occa- 
sionally with  a  jaundiced  colour  of  skin,  arising  from 
the  bile  not  getting  readily  into  the  ductus  communis 
choledochus,  on  account  of  the  pressure  of  the  in- 
flamed liver  on  the  pori  biliarii.  When  this  inflam- 
mation has  continued  for  some  time,  abscesses  are 
formed,  and  then  the  active  state  of  the  inflamma- 
tion very  much  subsides.  These  abscesses  are 
sometimes  of  large  size,  so  as  even  to  contain  some 
pints  of  pus.      Sometimes  the  whole  of  the  liver  is  al- 

•  Mav  nnt  the  purple  colour  atise  from  the  accumulation  of  blood  in  the 
branches  of  the  vena  portarum  ? 

As  this  vein  performs  the  office  of  a:i  artery  in  the  liver,  is  it  not  probable 
that  its  siiintl  branches  takvon  the  same  actions  z->  the  s  nail  branches  of  an 
aitcrj  during  iiuiainmatioo  ? 


C     132     ] 

most  converted  into  a  bag  containing  pus.  When  in- 
flammations of  the  liver  have  been  of  considerable 
standing,  they  are  not  uncommonly  attended  with  as- 
cites, and  the  water  is  of  a  yellow,  or  green  colour, 
being  tinged  by  the  bile. 

The  liver  has  sometimes  been  said  to  have  been  in 
a  state  of  mortification.*  This  however  occurs  very 
rarely,  and  has  never  fallen  under  my  own  observa- 
tion. 


Common  Tubercle  of  the  Liver. 

One  of  the  most  common  diseases  in  the  liver  (and 
perhaps  the  most  common,  except  the  adhesions 
which  we  have  lately  described,)  is  the  formation  of 
tubercles  in  its  substance.  This  disease  is  hardly  ev- 
er met  with  in  a  very  young  person,  but  frequently 
takes  place  in  persons  of  middle  or  advanced  age  : 
it  is  likewise  more  common  in  men  than  women. 
This  seems  to  depend  upon  the  habit  of  drinking  be- 
ing more  common  in  the  one  sex  than  in  the  other  ; 
for  this  disease  is  most  frequently  found  in  hard 
drinkers,  although  we  cannot  see  any  necessary  con- 
nection between  that  mode  of  life  and  this  particular 
disease  in  the  liver.  It  happens,  however,  very  com- 
monly, that  we  can  see  little  connection  between 
cause  and  effect,  in  changes  which  are  going  on  in  ev- 
ery other  part  of  the  body. 

The  tubercles  which  are  formed  in  this  disease  oc- 
cupy generally  the  whole  mass  of  the  liver,  are  placed 
very  near  each  other,  and  are  of  a  rounded  shape,  they 
give  an  appearance  every  where  of  irregularity  to  its 
surface.  When  cut  into,  they  are  found  to  consist  of 
a  brownish  or  yellowish  white  solid  matter.  'J  hey 
are  sometimes  of  a  very  small  size,  so  as  not  to  be 
larger  than  the  heads  of  large  pins,  but  most  fre- 
quently they  are  as  large   as   small  hazel  nuts,  and 

•  Vid.  Morgagni  Epist.  XXXIV,    Art.  25. 


L      133     ] 

many  of  them  are  sometimes  larger.  When  the  liver 
is  thus  tuberculated,  it  feels  much  harder  to  the  touch 
than  natural,  and  not  uncommonly  its  lower  edge  is 
bent  a  little  forward.  Its  size,  however,  is  generally 
not  larger  than  in  a  healthy  state,  and  I  think  it  is 
often  smaller.  If  a  section  of  the  liver  be  made  in 
this  state,  its  vessels  seem  to  have  a  smaller  diameter 
than  they  have  naturally.  It  very  frequently  happens 
that  in  this  state  the  liver  is  of  a  yellow  colour,  arising 
from  the  bile  accumulated  in  its  substance  ;  and  there 
is  also  water  in  the  cavity  of  the  abdomen,  which  is 
yellow  from  the  mixture  of  bile.  The  gall-bladder 
is  generally  much  contracted,  and  of  a  white  colour, 
from  its  being  empty.  The  bile,  from  the  pressure 
of  the  hard  liver  upon  the  pori  biliarii,  does  not  reach 
the  ductus  hepaticus,  and  therefore  cannot  pass  into 
the  gall-bladder.  The  colour  of  the  skin  in  such  ca- 
ses is  jaundiced,  and  it  remains  permanently  so,  as 
it  depends  on  a  state  of  liver  not  liable  to  change. 
This  is  the  common  appearance  of  what  is  generally 
called  a  schirrhus  liver  :  but  it  bears  only  a  remote 
resemblance  to  schirrhus.  as  it  shews  itself  in  other 
parts  of  the  body.  I  should  therefore  be  disposed  to 
consider  it  as  a  peculiar  disease  affecting  this  viscus. 

Large  White  Tubercle  of  the  Liver. 

Hard  white  masses  are  sometimes  formed  in  the 
liver.  They  are  often  as  large  as  a  chesnut  ;  but  I 
have  seen  them  both  a  good  deal  larger  and  smaller 
than  this  size.  They  are  to  be  found  near  the  sur- 
face of  the  liver  in  greater  number,  than  near  the 
middle  of  its  substance  :  two  or  three  frequently  lie 
contiguous  to  each  other,  with  a  considerable  por- 
tion of  the  liver,  in  a  healthy  state,  interposed  be- 
tween them  and  a  cluster  of  similar  tubercles.  They 
consist  of  a  very  firm,  opaque,  white  substance,  and 
are  generally  somewhat  depressed,  or  hollow,  upon 
their  outer  surface.     The  liver  in  this  disease  is  fre- 


[     134     ] 

quently  a  good  deal  enlarged  beyond  its  natural  size. 

These  tubercles  appear  to  be  first  formed  round  the 
blood  vessels  of  the  liver,  as  is  seen  in  making  sec- 
tions of  a  liver  in  this  state.  While  the  liver  is  un- 
der such  circumstances  of  disease,  there  is  sometimes 
water  in  the  cavity  of  the  abdomen,  and  at  other 
times  none  ;  the  liver  is  sometimes  tinged  in  its  col- 
our, from  the  accumulation  of  bile,  and  sometimes 
the  colour  of  its  substance  between  the  tubercles  is 
perfectly  natural. 

The  kind  of  tubercle  which  we  have  now  descri- 
bed, is  much  more  rare  than  the  other,  and  resem- 
bles more  the  ordinary  appearance  of  schirrhus  in  oth- 
er parts  of  the  body.  In  one  or  two  instances  of  it, 
however,  I  have  observed  a  thick  sort  of  pus,  resem- 
bling very  much  the  pus  from  a  scrofulous  sore  ; 
and  therefore  I  am  rather  disposed  to  think  that  this 
tubercle  mav  be  of  a  scrofulous  nature. 


Soft  brown  tubercles  of  the  Liver. 

I  have  also  seen  in  the  liver  a  number  of  soft  tu- 
mours, about  the  size  of  a  walnut  :  they  were  prin- 
cipally situated  at  the  surface  of  the  liver,  and  consist- 
ed of  a  smooth,  soft,  brownish  matter.  This  is  a  very 
rare  appearance  of  disease  :  such  tumours  would  by 
many  be  considered  as  scrofulous,  but  there  is  no 
strong  evidence  in  support  of  this  opinion  ;  and  there 
is  certainly  no  resemblance  between  this  sort  of  tu- 
mour, and  either  a  scrofulous  tubercle  of  the  lungs,  or 
a  scrofulous  absorbent  gland.  About  its  real  nature 
nothing  satisfactory  is  ascertained. 


Scrofulous  Tubercles  of  the  Liver, 

Tubercles  are  occasionally  found  in  the  liver, 
which  bear  a  strong  resemblance  to  the  tubercles  of 
the  lungs  ;  but  this  is  a  very  rare  appearance  of  dis- 


r  135  ] 

ease.  They  have  the  same  size,  the  same  structure, 
and  the  same  feeling  to  the  touch,  but  are  a  little 
browner  in  their  colour.  In  the  only  instance  which 
I  have  seen  of  this  disease,  the  tubercles  were  gener- 
ally dispersed  through  the  substance  of  the  liver  at 
pretty  regular  distances,  and  did  not  render  the  sur- 
face of  the  liver  irregular,  as  in  the  common  sort  of 
tubercle.  From  their  appearance  and  structure  I  can- 
not hesitate  to  consider  them  as  scrofulous. 


Liver  flaccid %  with  reddish  Tumours. 

I  have  likewise  seen  the  liver  much  more  flaccid  in 
its  membrane  than  is  natural,  with  reddish  tumours, 
of  considerable  size,  interspersed  through  it,  which 
contained  a  thick  sort  of  pus.  I  sm  inclined  to  con- 
sider this  liver  as  scrofulous,  because  it  was  found  in 
a  person  whose  general  constitution  had  strong  marks 
of  scrofula,  and  in  whom  also  were  found  many  scrof- 
ulous absorbent  glands  on  examining  the  body. 


Liver  very  soft  in  its  Substance. 

The  liver  is  not  unusually  found  much  more  flaccid 
in  its  substance  than  natural,  without  any  other  ap- 
pearance of  disease.  It  feels  upon  such  occasions 
nearly  as  soft  as  the  spleen,  and  is  commonly  of  a 
leaden  colour.  This  change  must  arise  from  a  pro- 
cess which  takes  place  through  its  whole  substance, 
and  seems  to  be  what  Mr.  Hunter  has  called  the  in- 
terstitial absorption.  By  this  process  is  meant,  the 
absorbents  removing  insensibly  the  very  minute  parts 
out  of  the  general  mass  of  any  structure  in  an  animal 
body  without  ulceration.  '1  his  state  of  liver  is  very 
rarely,  if  ever,  found  in  a  very  young  person,  and 
is  most  common  in  persons  who  are  advanced  in  life. 


[     136     ] 


Liver  very  hard  in  its  Substance. 

There  is  a  very  contrary  state  of  the  liver,  not  at 
all  unusual,  viz.  where  it  is  much  harder  than  natu- 
ral, and  when  cut  into,  exhibits  no  peculiar  struc- 
ture. Upon  the  surface  of  these  livers,  there  is  not 
uncommonly  a  thready  appearance  of  membrane,  dis- 
posed somewhat  in  a  radiated  form,  and  the  lower 
edge  is  bent  a  little  forwards.  This  I  believe  to  be 
the  first  step  in  the  progress  towards  the  formation  of 
the  common  tuberculated  liver.  I  have  sometimes 
seen  small  tubercles  formed  upon  a  part  of  the  surface 
of  such  a  liver,  which  were  exactly  of  the  common 
sort.  From  this  appearance,  it  is  probable,  that  ad- 
ditional matter  is  deposited  in  the  interstices,  through 
the  general  mass  of  the  liver,  rendering  it  much  hard- 
er, and  that  this  matter,  together  perhaps  with  part 
of  the  ordinary  structure  of  the  liver,  is  converted  into 
tubercles.  This  hardened  state  of  the  liver  is  some- 
times accompanied  with  a  beginning  ascites,  and 
sometimes  is  without  it. 


Hydatids. 

There  is  no  gland  in  the*  human  body  in  which 
hydatids  are  so  frequently  found  as  the  liver,  except 
the  kidneys,  where  they  are  still  more  common.* 
Hydatids  of  the  liver  are  usually  found  in  a  cyst, 
which  is  frequently  of  considerable  size,  and  is  form- 
ed of  very  firm  materials,  so  as  to  give  to  the  touch 
almost  the  feeling  of  cartilage.  This  cyst,  when  cut 
into,  is  obviously  laminated,  and  is  much  thicker  in 
one  liver  than  another.     In  some   livers   it  is  not 

•  Although  the  hydatids  of  the  liver,  and  the  kidney,  have  got  the  same 
name,  yet  most  frequentl)  they  differ  from  each  other.  Hydatids,  however, 
occasionally  occur  in  the  kidneys,  which  are  precisely  of  the  same  kind  with 
those  of  the  liver. 


[     137     ] 

thicker  than  a  shilling,  and  in  others,  it  is  near  a 
quarter  of  an  inch  in  thickness.  The  lamina;  which 
compose  it  are  formed  of  a  white  matter,  and  on  the 
inside  there  is  a  lining  of  a  pulpy  substance,  like  the 
coagulable  lymph.  The  cavity  of  the  cyst  I  have  seen, 
in  one  instance,  subdivided  by  a  partition  of  this  pulpy 
substance.  In  a  cyst  may  be  found  one  hydatid,  or 
a  greater  number  of  them.  They  lie  loose  in  the 
cavity,  swimming  in  a  fluid  ;  or  some  of  them  are  at- 
tached to  the  side  of  the  cyst.  They  consist  of  a 
round  bag,  which  is  composed  of  a  white,  semi- 
opaque,  pulpy  matter,  and  contain  a  fluid  capable  of 
coagulation.  Although  the  common  colour  of  hyda- 
tids be  white,  yet  I  have  occasionally  seen  some  of  a 
light  amber  colour.  The  bag  of  the  hydatid  consists 
of  two  laminae,  and  possesses  a  good  deal  of  contrac- 
tile power.  In  one  hydatid  this  coat,  or  bag,  is 
much. thicker  and  more  opaque  than  in  another,  and 
even  in  the  same  hydatid  different  parts  of  it  will  of- 
ten differ  in  its  thickness.  On  the  inside  of  an  hyda- 
tid, smaller  ones  are  sometimes  found  which  are  com- 
monly not  larger  than  the  heads  of  pins,  but  some- 
times they  are  even  larger  in  their  size  than  a  goosc- 
beny.  These  are  attached  to  the  larger  hydatid,  ei- 
ther at  scattered,  irregular  distances,  or  so  as  to  form 
small  clusters  :  and  they  are  also  found  floating  loose 
in  the  liquor  of  the  larger  hydatids.  Hydatids  of  the 
liver  are  often  found  unconnected  with  each  other  ; 
but  sometimes  they  have  been  said  to  inclose  each 
other  in  a  series,  like  pill-boxes.  The  most  com- 
mon situation  of  hydatids  of  the  liver,  is  in  its  sub- 
stance, and  inclosed  in  a  cyst;  but  they  are  occa- 
sionally attached  to  the  outer  surface  of  the  liver, 
hanging  from  it,  and  occupying  more  or  less  of  the 
general  cavity  of  the  abdomen. 

The  origin    and  real  nature  of  these    hydatids  are 
hot  fully  ascertained  ;  it  is  extremely  probable,  how- 
ever, that  they  are  a  sort  of  imperfect  animalcules. 
There  is  no  doubt,  that  the  hvdatids  in  the  livers  of 
S 


L      1*8     ] 

sheep  are  animalcules  :  they  have  been  often  seen  to 
move  when  taken  out  of  the  liver,  and  put  into 
warm  water  ;  and  they  retain  this  power  of  motion, 
for  a  good  many  hours  after  a  sheep  has  been  killed. 
The  analogy  is  great  between  hydatids  in  the  liver  of 
sheep,  and  in  that  of  the  human  subject.  In  both 
they  are  contained  in  strong  cysts,  and  in  both  they 
consist  of  the  same  white  pulpy  matter.  There  is 
undoubtedly  some  difference  between  them  in  simpli- 
city of  organization  ;  the  hydatid  in  the  human  liver 
being  a  simple  uniform  bag,  and  the  hydatid  in  that 
of  the  sheep  having  a  neck  and  mouth  appended  to 
the  bag.  This  difference  need  be  no  considerable 
objection  to  the  opinion  above  stated.  Life  may  be 
attached  to  the  most  simple  form  of  organization.  In 
proof  of  this,  hydatids  have  been  found  in  the  brains 
of  sheep,  resembling  almost  exactly  those  in  the  hu- 
man liver,  and  which  have  been  seen  to  move,,  and 
therefore  are  certainly  known  to  be  animalcules.  The 
hydatids  of  the  human  liver  indeed,  have  not  as  far 
as  I  know,  been  found  to  move  when  taken  out  of 
the  body  and  put  into  warm  water ;  had  this  ever 
happened,  no  uncertainty  would  remain.  It  is  not 
difficult  to  see  a  good  reason  why  there  will  hardly 
occur  any  proper  opportunity  of  making  this  experi- 
ment. Hydatids  are  not  very  often  found  in  the  liv- 
er :  and  the  body  is  allowed  to  remain  for  so  long  a, 
time  after  death  before  it  is  examined,  that  the  hyda- 
tids must  have  lost  their  living  principle,  even  if  they 
were  animalcules.  The  probability  of  their  being  an- 
imalcules, however,  is  very  strong  ;  and  it  appears 
even  more  difficult  to  account  for  their  production  ac- 
cording to  the  common  theory  of  generation,  than 
for  that  of  intestinal  worms.  We  do  not  get  rid  of 
the  difficulty  by  asserting,  that  hydatids  in  the  human 
liver  are  not  living  animals,  because  in  sheep  they 
are  certainly  such,  where  the  difficulty  of  accounting 
for  their  production  is  precisely  the  same.  If  any 
person  should  wish  to  consider  hydatids  more  mi- 
nutely, he  will  find  an  excellent  accountof  them  pub- 


C     139     ] 

lished  by  Dr.  John  Hunter  in  the  Medical  and  Chi- 
rurgical  Transactions.* 

Cysts  in  the  Liver  containing  an  Earthy  Matter. 

Cysts  are  occasionally  formed  in  the  liver  contain, 
ingan  earthy  matter.  The  cysts  are  composed  of  a 
kind  of  cartilaginous  substance  mixed  with  bone. 
The  earthy  substance  contained  in  the  cyst  is  soft, 
smooth,  and  of  a  brownish  white  colour.  It  is  mix- 
ed with  soft  films,  resembling  a  good  deal  in  their  ap- 
pearance the  coats  of  an  hydatid. 

Rupture  of  the  Liver. 

The  liver  is  more  liable  to  be  ruptured  by  external 
violence  than  any  other  gland  of  the  body,  which 
probably  arises  from  two  causes  :  the  one  is,  that  in 
thin  persons  the  liver,  more  especially  when  large, 
lies  near  the  surface  of  the  body,  and  therefore  may 
be  readily  affected  by  a  strong  external  pressure. 
The  other  is,  that  the  liver  consists  of  a  structure, 
the  parts  of  which  arc  more  easily  separated  from 
each  other  by  pressure,  than  those  of  almost  any  oth- 
er organ  or  structure  in  the  body.  Thus,  if  the 
thumb  or  the  finger  be  pressed  against  the  liver  with 
a  good  deal  of  force,  the  liver  gives  way  much  in  the. 
same  manner  as  a  rotten  pear  would  do,  although  not 
so  readily.  In  this  trial  the  effect  dots  not  depend 
upon  the  liver  being  softened  by  putrefaction,  because 
it  will  take  place  in  the  liver  of  a  person  immediately 
after  death.  It  depends  upon  the  peculiar  structure 
of  the  liver,  and  therefore  may  take  place  in  the  liver 
of  a  person  who  is  alive,  as  well  as  of  one  who  is 
elcad.  If  the  same  degree  of  pressure  be  applied  to 
a  muscle,  or  many  glands  of  the  body,  they  arc  not 
ruptured,  but  recover  themselves  after  the  pressure 

•  See  Med.  and  Chirurgical  Trans,  p.  34.  • 


C    i4©    ] 

has  been  removed.  When  ruptures  have  taken  place 
in  the  liver,  they  have  happened  from  some  strong 
pressure  applied  to  the  upper  part  of  the  abdomen  ; 
as  for  instance,  from  the  wheel  of  a  carriage  passing 
over  that  part  of  the  body.  Little  pain  has  been  felt 
from  such  an  injury  ■  which  is  a  proof  among  many 
others  of  the  liver  not  possessing  much  sensibility ; 
and  some  of  the  persons  to  whom  this  accident  has 
happened  have  continued  to  live  after  it  for  several 
days. 


Worms  said  to  be  in  the  Livtr* 

Worms*  have  been  said  to  be  found  in  cysts  of 
the  liver,  as  well  as  in  the  biliary  ducts.  Instances 
of  this  sort  are  extremely  rare,  and  have  not  come 
Under  my  own  observation. 


SYMPTOMS. 


When  the  coats  of  the  liver  are  inflamed,  more  es- 
pecially upon  its  convex  surface,  the  symptoms  cor- 
respond a  good  deal  with  those  of  pleurisy,  in  which 
the  inflammation  has  attacked  the  lower  part  of  the 
pleura  upon  the  right  side.  There  is  acute  pain  in  the 
part  affected,  difficulty  of  breathing,  cough,  and  symp- 
tomatic fever.  The  two  affections  may  however  be, 
in  general,  distinguished  from  each  other  by  the  fel- 
lowing  circumstances.,     Where  the  coats  of  the  liver 

*  Vic!.  Lieutafldj  Tom.  I.  p    194. 


L    i4i    ] 

arc  inflamed  the  pain  will  be  less  increased  upon  deep 
inspiration  than  where  the  pleura  at  the  lower  part  of 
the  right  side  of  the  chest  is  inflamed.  In  inflamma- 
tion of  the  coats  of  the  liver  there  will  be  a  considera- 
ble increase  of  pain  upon  pressure  immediately  under 
the  margin  of  the  ribs  on  the  right  side,  which  will 
not  take  place  in  inflammation  of  the  pleura. 


lam  not  acquainted  with  any  symptoms  which  at- 
tend adhesions  of  the  liver  to  the  neighbouring  parts. 


When  the  substance  of  the  liver  is  inflamed,  there 
is  an  obtuse  pain  in  the  right  hypochondrium,  and  a 
pain  is  often  felt  at  the  top  of  the  right  shoulder. 
The  patient  can  lie  most  easily  on  the  side  affected. 
There  is  more  or  less  of  symptomatic  fever,  some- 
times a  dry  cough,  sometimes  hickup,  sometimes 
vomiting,  and  occasionally  a  yellow  colour  of  the  skin 
and  eyes.  Inflammation  of  the  substance  of  the  liver 
sometimes  takes  place  so  very  slowly,  that  it  is  hardly 
attended  with  any  pain,  and  the  constitution  is  not  at 
all  or  very  little  affected  with  symptoms  of  fever.  On 
such  occasions  an  inflammation  of  the  liver  is  not 
suspected  till  an  abscess  has  actually  been  formed,  and 
begins  to  make  its  progress  outwards. 


I  know  of  no  peculiar  symptoms  by  which  the  liv- 
er can  be  ascertained,  in  the  living  body?  to  be  stud- 
ded with  tubercles.  When,  however,  there  is  pain 
or  an  uneasy  feeling  in  the  region  of  the  liver,  togeth- 
er with  a  jaundiced  colour  of  the  skin,  which  contin- 
ues permanent,  and  water  is  at  the  same  time  accu- 
mulated in  the  cavity  of  the  abdomen  ;  there  remains 
little  doubt  of  the  liver  being  tuberculated.  When 
the  parictes  of  the  abdomen  are  thin,  and  water  is  ac- 


[     142     ] 

cumulated  in  small  quantity  in  that  cavity,  the  tuber- 
cles at  the  lower  edge  of  the  liver  can  sometimes  be 
distinctly  felt  by  the  fingers,  upon  an  attentive  ex- 
amination. 


The  symptoms  which  belong  to  the  large  white  tu- 
bercle of  the  liver,  I  cannot  distinguish' from  those 
of  the  common  tubercle.  Sometimes,  however, 
when  the  person  is  thin  and  the  tubercles  are  near  the 
lower  edge  of  the  liver,  they  can  be  distinguished  by 
an  external  examination.  I  believe  that  the  large 
white  tubercle  is  not  so  often  attended  with  jaundice 
and  ascites  as  the  other. 


The  symptoms  which  belong  to  the  other  tubercles 
of  the  liver  are  unknown  to  me.  I  am  disposed  to 
think  that  there  are  none  which  may  be  called  dis- 
criminative. 


When  the  liver  is  becoming  hard  in  its  substance, 
the  exact  state  of  it  cannot  be  determined  in  the  liv- 
ing body,  unless  the  person  be  so  thin  that  the  liver 
can  be  distinctly  felt  upon  examination.  This,  how- 
ever, will  frequently  be  very  difficult,  and  on  many 
occasions  impossible  ;  because  the  liver,  when  hard, 
is  commonly  not  increased  in  its  size,  and  the  parietes 
of  the  abdomen  arc  of  considerable  thickness.  If 
there  be  some  sense  of  uneasiness  in  the  region  of  the 
liver,  along  with  a  sallow  countenance,  this  disease 
may  be  suspected.  It  has  sometimes  happened,  how- 
ever, that  the  liver  has  been  discovered  to  be  hard, 
upon  an  examination  after  death,  when  no  symptoms 
had  been  observed  during  life  which  led  to  an  opin. 
ion  of  this  disease  having  tafe  n  place. 


[     143     ] 


There  are  no  symtoms  which  characterize,  partic- 
ularly, the  formation  of  hydatids  in  the  liver,  and  this 
disease  can  only  be  guessed  at  in  the  living  body.  It 
appears  from  the  history  of  some  cases  of  this  kind, 
that  a  pain  is  felt  in  the  right  hypochondrium  ;  but 
this  may  arise  from  many  other  causes. 

In  two  cases  which  have  come  to  my  knowledge 
the  symptoms  were  similar  to  those  which  attend  an 
attack  of  gall-stones.  There  was  a  violent  spasmodic 
pain  near  the  pit  of  the  stomach,  frequent  vomiting, 
and  jaundice,  with  a  pulse  not  accelerated.  These  at- 
tacks occurred  frequently  in  both  cases  after  consider- 
able intervals  of  tolerably  good  health. 

When  hydatids  are  confined  within  the  substance 
of  the  liver,  I  do  not  see  how  it  is  possible  that  their 
existence  should  be  ascertained  ;  but  when  they  are 
formed  on  the  outer  surface  of  the  liver,  near  its  lower 
edge,  their  existence  may  in  some  degree  be  ascer- 
tained by  examination,  more  especially  if  the  person 
be  thin.  When,  however,  the  parictcs  of  the  abdo- 
men are  thick,  and  the  hydatids,  or  their  cysts  are 
not  distinct,  but  lie  in  contact  with  each  other,  ma- 
king an  irregular  tumour,  it  will  hardly  be  possible 
to  form  an  accurate  opinion  by  an  examination.  If 
the  tumour  be  formed  gradually,  and  the  general 
health  be  little  affected,  it  is  probable  that  it  consists 
of  hydatids.  An  accurate  attention  to  the  feeling, 
which  the  tumour  yields  upon  pressure,  or  upon  stri- 
king it  gently  with  the  hand,  may  also  assist  inform- 
ing a  probable  conjecture  about  its  nature.  Where 
the  tumour  consists  of  hydatids,  il  will  generally  feel 
to  a  certain  degree  soft  ;  and  if  the  hydatids  should 
be  very  large,  there  will  probably  be  an  obscure  sense 
of  fluctuation  upon  striking  the  tumour  with  one 
hand,  while  the  other  is  applied  to  the  opposite  side 


[     144     ] 

of  it.  If  moreover,  the  tumour  should  occupy  a 
great  part  of  the  cavity  of  the  abdomen,  and  can  be 
clearly  traced  from  the  liver,  as  the  source  of  its 
growth,  there  can  be  little  doubt  of  the  existence  of 
hydatids  under  these  circumstances. 


Cv    145     J 


CHAP.  X. 


BISEASED    APPEARANCES    IN  THE  GALLBLADDER, 


Inflammation  of  its  Coats. 


T 


HE  coats  of  the  gall-bladder  arc  very  rarely  in- 
flamed, without  inflammation  of  the  membrane  which 
covers  the  posterior  surface  of  the  liver.  When  inflam- 
mation attacks  this  membrane,  it  naturally  spreads 
over  the  outer  coat  of  the  gall-bladder,  which  is  a  con- 
tinuation of  it,  and  may  affect  the  other  coats  of  the 
gall-bladder,  if  it  should  have  arisen  to  a  violent  de- 
gree. Inflammation,  however,  of  the  outer  coat  of 
the  gall-bladder  will  not  commonly  be  attended  with 
inflammation  of  the  others,  because  it  is  not  closely 
applied  to  them,  there  being  interposed  a  considera- 
ble quantity  of  cellular  membrane.  The  appearances 
of  inflammation  in  the  coats  of  the  gull  bladder,  are 
bimilar  to  what  tuLe  place  in  the  inflammation  of  the 
stomach  or  intestines.  These  have  been  already  fullj 
described,  and  need  not  be  repeated. 


Adhesions. 

It  is  a  very  cjommon  appearance,  upon  dissection, 
to  iind  the  gall-bladder  connected  by  adhesions,  ei;- 


[      14.6.    ] 

ther  to  the  small  end  of  the  stomach,  or  tkc  begin* 
ning  of  the  duodenum.  These  are  the  consequence 
of  a  previous  inflammation  in  the  outer  coat  of  the 
gall-bladder,  and  resemble  exactly  the  adhesions 
which  we  have  already  described. 


Ulcers  in  the  Gall-Bladder. 

It  is  rare  that  inflammation  of  the  gall-bladder  ad- 
vances to  ulceration  :  the  accumulation  of  gall-stones 
in  it,  as  far  as  I  have  observed,  rarely  produces  this 
effect.*  Ulceration  of  the  gall-bladder,  however, 
occasionally  takes  place,  and  I  believe  almost  always 
begins  in  the  inner  membrane.  Of  this  I  have  known 
two  cases.  In  the  one  case,  several  ulcers  were  found 
hi  the  inner  membrane  of  the  gall-bladder,  while  the 
other  coats  were  not  affected  ;  and  in  the  other  there 
was  one  ulcer  which  had  destroyed  a  part  of  all  the 
coats. 


Coats  of  the  Gall-bladder  tJvckenedy  and  hard  Tuber- 
cles formed  in  them. 

I  have  only  had  an  opportunity  once  of  observing 
this  change  in  the  gall-bladder.  Its  eoats  were  above 
a  quarter  of  an  inch  thick,  and  were  studded  with  tu- 
bercles of  a  considerable  size,  and  very  firm  in  their 
texture.  The  liver  to  whi<fh  this  gall-bladder  be- 
longed was  affected  with  the  same  disease. 

Coats  of  the  Gall-bladder  bony. 

I  have  likewise  seen  the  coats  of  the  gall-bladder 
very  much  thickened,  and   converted  in  many  parts 

•  Pr.  Soemmerr'm;;,  however,  has  seen  a  good  many  instances  of  ulcers 
irvtke  inner  sitrface  «f  the  giiK-bladder,  from  the  irritation  of  gall-6'biie3. 


[     147     ] 

into  a  sort  of  bony  substance  ;  but  tms  is  to   be  con- 
sidered as  a  very  rare  appearance  of  disease. 


Diseased  state  of  the   Biliary  Ducts. — Their  Dilata- 
tion. 

The  most  common  diseased  appearance  of  the  bil- 
iary ducts  is  their  dilatation.  The  ductus  hepaticus, 
ductus  cysticus,  and  ductus  communis  choledochus, 
are  sometimes  dilated  to  an  almost  incredible  size. 
I  have  seen  the  ductus  hepaticus  and  choledochus  so 
much  dilated  as  to  be  nearly  an  inch  in  the  transverse 
diameter.  These  dilatations  of  the  biliary  ducts  take 
place  in  consequence  of  the  passage  of  gall-stones  ; 
and  it  is  astonishing  how  large  gall-stones  sometimes 
are,  which  have  been  known  to  pass  into  the  duode- 
num. This  ought  to  afford  a  stroug  ground  of  com- 
fort to  persons  who  arc  labouring  under  this  com- 
plaint. 


Obliteration  of  the  Biliary  Ducts. 

An  obliteration  of  any  of  the  biliary  ducts  happens 
very  rarelv,  but  instances  of  this  disease  have  been 
discovered,  and  they  may  be  traced  to  the  following 
causes.  One  cause  is  a  violent  inflammation,  which 
has  taken  place  in  the  inner  surface  of  some  of  the  bil- 
iary ducts,  and  has  terminated  in  an  adhesion  of  its 
sides.  This  may  be  supposed  to  arise  most  com- 
monly from  the  irritation  of  a  rough  gall-stone,  in  its 
passage  towards  the  duodenum.  A  similar  adhesiou 
has  been  known  to  take  plaee  in  oilier  canals  of  the 
body,  in  consequence  of  violent  inflammation  there, 
as,  for  instance,  in  the  vagina.  Another  cause, 
which  may  act  upon  the  lower  extremity  of  the  duc- 
tus communis  choledochus,  obliterating  its  cavity  at 
that  part,  is  a  violent  inflammation  of  the  duodenum 
at  the  entrance  of  the  duct ;  the  extremity  of  the  duet 


[   143   3 

being  involved  in  the  inflammation,  may  have  its  ca» 
nal  obliterated.  To  this  may  be  added,  as  a  third 
cause  of  obliteration,  a  scirrhus,  or  any  other  enl- 
argement of  the  round  head  of  the  pancreas,  which 
may  so  press  upon  the  lower  extremity  of  the  ductus 
communis  choledochus>  as  to  annihilate  its  cavity. 
It  has  only  occurred  to  myself  to  have  seen  an  in- 
stance of  obliteration  in  the  ductus  cysticus  ;  but  Dr. 
Storer,  of  Nottingham,  whose  ability  and  industry  in 
his  profession  are  well  known,  has  favoured  me  with 
an  account  of  two  cases  of  obliteration  at  the  end  of 
the  ductus  communis  choledochus. 


A  preternatural  Canal  of  Communication  between  the 
Gall-bladder  and  the  Stomach. 

It  may  not  be  improper  to  take  notice  here,  that  I 
have  once  seen  an  immediate  communication,  by  a 
short  canal  between  the  gall-bladder  and  the  small 
end  of  the  stomach.  This  lusus  nature  is  very  rare> 
and  but  a  few  instances  of  it  have  been  recorded. 


Gall-stones. 

It  is  not  an  uncommon  appearance  of  disease  in  ex^- 
amining  dead  bodies,  to  find  gall-stones,  either  in  the 
gall-bladder,  or  in  some  of  the  biliarv  ducts.  The 
gall-bladder  is  sometimes  much  enlarged  in  its  size, 
and  full  of  them.  In  this  case  its  coats  are  often  a 
good  deal  thickened,  which  arises  partly  from  the 
pressure  against  the  gall-bladder,  in  consequence  of 
the  accumulation  of  the  stones,  and  partly  from  the 
efforts  of  the  contractile  power  of  the  gall-bladder  to 
expel  them.  The  number  of  stones  accumulated  in 
the  gall-bladder  is  sometimes  very  great ;  above  a 
thousand  have  been  taken  out  of  one  gall-bladder,, 
which  are  preserved  in  Dr.  Hunter's  collection. 
'When  there  is  a  solitary  gall-stone  in  the  gall-bladder, 


[     149     ] 

\\  is  occasionally  very  large  ;  I  have  known  an  in* 
stance  of  one  which  was  fully  the  size  of  a  hen's  egg. 
When  there  is  but  one  gall-stone  either  in  the  gall- 
bladder, or  in  the  biliary  ducts,  it  is  generally  of  an 
oval  shape  ;  when  there  is  a  considerable  number, 
thev  acquire,  by  rubbing  upon  each  other,  in  a  small 
space,  a  great  many  sides  and  angles. 

There  is  prc.it  variety  in  the  external  appearance  of 
gall-stones  as  to  colour  :  some  are  whitish,  others  are 
black;  they  are  also  of  a  yellowish,  a  greenish,  a 
light  brown,  a  dark  brown,  and  areddish  brown  colour. 
These  are  the  principal  varieties  in  colour,  but  there 
are  many  other  smaller  differences  which  it  is  very 
difficult  to  express  in  words.  Gall-stones  differ  also 
very  much  in  the  state  of  their  surface,  some  being 
verv  smooth,  and  others  a  good  deal  roughened. 

When  cut  or  broken,  gall-stones  are  commonly 
found  to  consist  of  concentric  laminae  upon  the  out- 
side, and  in  the  centre  of  a  radiated  structure.  The 
laminated  part  bears  sometimes  a  great  proportion  to 
the  other,  and  sometimes  the  contrary  happens.  The 
laminated  and  radiated  structures  are  sometimes  com- 
pact, and  sometimes  consist  of  a  more  loose  matter. 
It  likewise  occasionally  happens  that  both  the  lamin- 
ated and  the  radiated  structures  are  very  obscure,  and 
the  gall-stone  appears  a  good  deal  like  an  uniform 
solid  mass.  The  laminated  part  on  the  outside  vc  in- 
frequently consists  of  a  different  substance,  in  appear, 
anee,  from  the  radiated  structure  in  the  centre  ;  v.nd 
it  is  not  unusual  to  find  the  structure  in  the  centre  to 
consist  of  shining,  white  crystallizations,  which  have 
a  good  deal  the  look  of  mica  or  spermaceti. 

Gall-stones  being  very  different  both  in  their  out- 
ward appearance  and  their  internal  structure  from 
each  other,  we  are  naturally  led  to  supose  that  they 
may  also  differ  in  their  chemical  properties.  Upon 
this  subject  I  can  only  speak  very  generally  ;  but  su  li 
trials  as  I  have  made  incline  me  to  this  opinion. 
Very  few  gall-stones  yield  a  bitter  taste,  which  shew  -i 
that  commonly  they  do  not  consist  of  inspissated  bile; 


[     150     ] 

but  in  some  I  have  found  the  taste  intense!)''  bitter. 
Almost  all  of  them  melt  in  the  flame  of  a  candle  ;  but 
I  have  met  with  one  sort,  of  a  very  black  colour, 
which  did  not  melt,  but  burnt  exactly  like  a  cinder.* 

All  the  gall-stones  which  I  have  examined  dissolve 
in  the  nitrous  acid.  They  are  separated  into  a  fine 
black  powder  when  put  into  the  vitriolic  acid,  espe- 
cially if  exposed  to  a  sand  heat.  By  the  marine  acid 
they  are  not  acted  upon  at  all  in  the  common  heat  of 
the  atmosphere  ;  and  are  even  but  little  affected  by 
it  when  exposed  to  a  sand  heat  for  a  considerable 
time. 

Most  of  the  gall-stones  which  I  have  examined,  are 
either  not  very  soluble  in  oil  of  turpentine,  in  the  com- 
mon heat  of  the  atmosphere,  or  the  process  goes  on 
very  slowly  :  one  sort  I  have  found  to  be  in  this  heat 
altogether  insoluble.  When  put  into  this  oil,  and 
exposed  to  a  sand  heat,  they  are  much  more  readily 
acted  upon.  Some  are  converted  into  a  kind  of  oil, 
which  sinks  to  the  bottom  of  the  oil  of  turpentine  ; 
others  are  partly  soluble,  tinging  the  oil  of  turpen- 
tine of  a  brownish  colour,  and  are  partly  separated  in- 
to a  powder. 

Most  gall-stones  appear  not  to  be  readily  affected 
by  the  spirit  of  wine  in  the  common  heat  of  the  at- 
mosphere, but  are  either  partly  or  entirely  soluble  in 
it  in  a  boiling  heat.f  Such  are  the  general  results 
from  a  good  many    trials  of  my  own,  but  I  should 

*  Dr.  Scemmer; ing  cr.riEMiiers  these  as  inspissated  bile,  and  mentions,  that 
they  have  no  regular  form,  have  a  bitter  taste,  and  are  soluble  in  water.  In 
some  trials  which  I  made  they  did  not  dissolve  in  distilled  water,  either  cold 
<r  hot  ;  but  they  are.  bitter  to  the  taste,  and  without  any  regular  shape,  or  ap- 
pearance of  en  stallization. 

f  When  tome  biliary  calculi  are  exposed  to  spirit  o'f  wine  in  a  boiling  state. 
w\iite  flaky  crystals  arc  soon  formed  upon  its  cooling.  When  they  are  expo- 
sed to  spirit  of  wine  in  the  common  heat  of  the  atmosphere,  it  is  some  weeks 
before  crystals  begin  to  be  formed,  and  they  appear  to  be  more  pointed  in 
their  shape  than  the  former.  These  crystals  were,  I  believe,  first  observed  by 
M  Poullcrier  az  la  Salle.  See  Clemens  d'Uistoire  Naturalle  et  de  Chinne, 
p  i  M-  ck-  Fourcroy,  T«m,  IV,  p    354. 


[  151  ] 

rest  upon  them  with  little  confidence,  if  they  did  not 
in  a  great  measure  correspond  with  those  of  the  ex- 
periments of  others,  who  are  more  conversant  than  my- 
self both  with  the  scientific  and  practical  part  of 
chemistry. 

Gall-stones,  according  to  the  experiments  of  Grcn, 
consist  of  a  substance  possessing  the  properties  of 
wax,  and  of  lymph.* 

A  gall-stone,  consisting  of  a  chocolate  coloured 
substance  on  the  outside,  and  of  white,  radiated  1am- 
in;r  upon  the  inside,  was  found  by  Dr.  Saunders  to 
consist  of  a  resinous  matter,  with  a  small  proportion 
of  earth,  apparently  the  calcareous,  and  some  min- 
eral and  volatile  alkali. f 

The  gall-stones  which  Dr.  P#wcll  examined  were 
found  to  consist  of  resinous  matter,  carbonc,  and  an 
animal  substance  resembling  dried  mucus. J  This 
subject  seems  still  to  be  imperfectly  known,  and  to 
require  further  investigation. 


Bile. 

The  bile  in  the  gall-bladder  is  found  to  differ  in 
different  bodies  ;  but  this  is  too  common  to  arise 
from  disease,  and  must  depend  on  natural  circumstan- 
ces. It  is  sometimes  of  a  green,  at  other  times  of  a 
brownish  yellow,  or  a  purer  yellow  colour.  The 
brownish  yellow  colour  is  the  most  common.  It  is 
always  more  or  les*  viscid,  and  the  variety  in  this 
respect  is  considerable  :  in  man  it  generally  appears 
a  good  deal  more  viscid  than  in  most  other  classes  of 
animals.  In  one  case,  I  have  seen  it  as  ropy  as  the 
mucus  which   is   commonly  coughed   up  from   the 

•  See  Johnson's  Animal  Chemistry,  Vol.  ?,  p    355. 

t  See  Dr.  Saundet'sTreatiBeuD  ihe  Liver,  p.  119,  first  adS^m. 

\  SeeDr.  Powell's  Objcrw.ions  en  the  Eiie  and  its  uiseas-s. 


L     152     ] 

trachea.  I  recollect  also  another  case,  where  the 
bile  in  the  gall-bladder  resembled  exactly  the  white 
of  a  raw  egg.  This  kind  of  substance  is  ascertained 
to  form  one  of  the  constituent  parts  of  the  bile,  and 
in  the  present  instance  it  would  seem  that  the  other 
parts  were  wanting.  Such  an  effect  may  be  supposed 
te  have  depended  upon  a  very  imperfect  action  of  the 
secretory  structure  of  the  liver.  The  liver  was  not 
sound,  being  studded  with  scrofulous  tubercles,  and 
the  absorbent  glands  of  the  mesentery  were  affected 
with  the  same  disease. 

In  opening  dead  bodies,-  the  bile  is  almost  always 
found  to  have  transuded  in  small  quantity  through 
coats  of  the  gall-bladder,  so  as  to  tinge  the  neigbour- 
ing  parts,  cspcciall^the  small  end  of  the  stomach  and 
the  beginning  of  the  duodenum.  This  is  to  be  consid- 
ered as  a  natural  effect,  which  has  taken  place  after 
death,  and  not  as  a  diseased  appearance.  The  coats 
of  the  gall-bladder,  inconsequence  of  death,  have  lost 
that  compactness  by  which  they  were  formerly  able  to 
confine  the  bile  ;  it  therefore  transudes  in  small  quan- 
tity, and  tinges  the  neighbouring  parts. 


Gall-bladder  distended  with  Bik\ 

The  gall-bladder  is  sometimes  distended  with  bile 
so  as  to  be  of  nearly  twice  its  usual  size  ;  at  other  times 
there  is  no  bile  at  all  in  its  cavity,  and  under- such 
circumstances  it  is  white  in  its  colour,  aud  contracted 
into  very  small  size. 


Hydatids  in  the  Gall-bladder* 

The  gall-bladder  has  been  known  to  be  distended 
to  an  immense  size,  and  to  contain  hydatids  •*  but 
this  state  of  it  is  to  be  considered  as  extremely  uncom- 
mon. 

*  Se:  Medical  Communications,  Vol.    I.  p.  10!», 


C     153     ] 

The  Gall-bladder  wanting. 

The  gall-btadder  has  also  been  known  to  be  want- 
ing from  a  defect  in  the  original  formation.*"  Tt  has 
never  occurred  to  me  to  see  an  example  of  this  kind 
of  monstrosity  ;  but  it  may  be  the  more  readily  be- 
lieved sometimes  to  happen,  as  the  gall-bladder  does 
not  serve  any  necessary  purpose  in  the  body.  There 
are  many  classes  of  animals  which  are  naturally  with- 
out a  gall-bladder. 


SYMPTOMS* 


Inflammation  of  the  coats  of  the  gall-bladder  is  not 
known  to  be  distinguished  by  any  peculiar  symptoms. 
They  are  probably  much  the  same  with  the  symp- 
toms which  attend  inflammation  of  the  membranous 
covering  of  the  liver. 

An  obliteration  cither  of  the  hepatic  duct,  or  of  the  duc- 
tus communis  choledochus,  must  produce  a  jaundice 
which  is  permanent,  because  it  depends  upon  a  cause 
not  liable  to  change.  This  will  be  extremely  difficult 
to  distinguish,  in  practice,  from  jaundice  produced 
by  a  hardened,  or  tuberculated  state  of  the  liver,  for 
this  cause  of  jaundice  may  likewise  be  said  to  be  gen- 
erally permanent.  When  the  ductus  cysticus  only  is 
obliterated,  there  will  be  no  jaundice,  and  little  in- 
convenience will  probably  be  felt,  unless  the  bile 
'  on  fined  in  the  gall-bladder  should  at  length  irritate 

*  Sec  Dr.  Soemmerrhig's  Germ.  Trans,  p.  15#. 

u 


[     154     ] 

its  coats.  In  this  case  inflammation  may  be  excited, 
which  may  advance  to  suppuration.  I  have  seen  an 
ulcer  of  the  gall-bladder,  which  appeared  to  be  piO' 
duced  by  this  cause. 


While  gall-stones  remain  in  the  gall-bladder,  and 
no  attempt  is  made  towards  their  passing  through  the 
ductus  cysticus,  and  ductus  communis  choledochus, 
very  little  inconvenience  is  commonly  produced  by 
them.  It  frequently  happens  that  gall-stones  are 
found  in  the  gall-bladder  after  death,  where  there  was 
not  the  least  suspicion  of  their  existence  during  life. 
When  they  pass  through  the  ducts,  more  especially 
if  they  be  large  in  their  size,  a  most  excruciating 
pain  is  commouly  felt  about  the  pit  of  the  stomach  : 
patients  in  this  case  express  a  much  stronger  feeling 
of  pain,  than  during  a  violent  inflammation  even  in 
the  most  sensible  parts  of  the  body.  They  often  cry 
out,  and  writhe  or  twist  their  body  into  various  pos- 
tures. When  the  pulse  is  felt  during  this  exquisite 
pain,  it  is  sometimes  found  to  be  accelerated  in  a  very 
trifling  degree,  but  generally  it  is  not  more  frequent 
than  in  health,  and  sometimes  it  is  even  slower. 
There  is  languor,  sickness,  and  vomiting  :  and  the 
skin  becomes  in  the  progress  of  the  disease  more  or 
less  of  a  yellow  colour. 


r  155  3 


CHAP.  XI. 


DISEASED     APPEARANCFS   OF  THE   SPLEEK- 


Inflammation  of  the  Coats  of  the  Spleen. 


HP 

JL  HE  coats  of  the  spleen  are  liable  to  inflamma- 
tion ;  but  this  rarely  takes  place  unless  the  periton  e- 
um  in  the  neighborhood  be  also  affected.  The  prop- 
er capsule  of  the  spleen  is  so  intimately  connected 
with  the  peritonaeum  which  is  reflected  over  it,  that  it 
must  necessarily  partake  of  any  inflammation  affect- 
ing that  portion  of  the  membrane.  When  inflamma- 
tion attacks  the  coats  of  the  spleen,  it  exhibits  exact- 
ly the  same  appearances  which  have  been  so  often 
described.  They  become  much  more  crowded  with 
ilorid  blood  vessels  than  in  a  natural  state,  are  some- 
what thicker,  and  throw  out  a  layer  of  coagulable 
lymph  upon  their  surface. 

Adhesions. 

It  is  more  common,  however,  to  find  adhesions 
formed  between  the  spleen  and  the  neighbouring 
parts,  than  to  find  its  coats   in  an  actual  state  of  in- 


C     156     ] 

^animation.  These  adhesions  consist  of  a  white, 
transparent  membrane,  of  more  or  less  firmness,  and 
generally  connect  the  broad  surface  of  the  spleen 
more  or  less  closely  to  the  diaphragm.  They  often 
connect  too  the  spleen  to  the  great  end  of  the  stom- 
ach, and  a  part  of  the  transverse  arch  of  the  colon. 

Inflammation  of  the  substance  of  the  Spleen. 

It  is  very  rare  to  find  the  substance  of  the  spleen 
either  in  a  state  of  inflammation  or  suppuration  ;  but 
such  cases  have  occasionally  been  observed  and  rela- 
ted by  authors.*  Instances  also  have  been  related 
where  the  spleen  had  been  observed  to  be  mortified  ;t 
but  thb  is  probably  much  more-rare  than  the  former. 

The  Spleen  extremely  soft. 

There  is  an  appearance  of  the  spleen  which  is  very 
common,  and  which  perhaps  is  hardly  to  be  consid- 
ered as  a  disease,  but  it  is  a  very  obvious  de- 
viation from  its  healthy  structure. .  The  appearance 
to  which  I  allude  is  an  extreme  softness  of  the  spleen, 
so  that  when  its  capsule  is  broken  (which  under  such 
circumstances  is  very  tender)  the  substance  of  the 
spleen  seems  to  consist  of  little  else  than  a  very  soft, 
brownish  red  mucus,  intermixed  with  a  spongy  fi- 
brous texture.  This  appearance  of  the  spleen  is 
hardly  ever  to  be  observed  at  a  very  early  period  of 
life,  but  is  very  common  in  middle  and  more  advan- 
ced age.  I  believe  that  such  a  slate  of  the  spleen  is  not 
marked  by  any  peculiar  feelings,  so  as  to  make  the 
persons  conscious  of  any  disease  taking  place,  and  is 
probably  of  very  little  consequence    in  the  general 

*   Vid.  Lieutaud,  Tom.  I.  p.  222. 
f  Vid.  i.ieuta';id,  Tom.  I.  223. 


[     157     ] 

economy  of  the  animal.  Still,  however,  it  is  not  a 
state  into  which  the  spleen  naturally  degenerates  in 
the  gradual  decay  of  the  body. 


The  Spleen  very  hard. 

The  spleen  is  sometimes  much  harder  than  natu- 
ral, and  at  the  same  time  is  generally  a  good  deal  en- 
larged. It  will  occasionally  be  enlarged  to  five  or  six 
times  its  natural  size,  and  it  then  forms  a  tumour, 
very  capable  of  being  distinguished  by  an  examina- 
tion in  the  living  body.  When  cut  into,  the  natu- 
ral structure  seems  to  be  preserved,  except  that  it 
is  much  more  compact,  the  parts  being  much  more 
closely  applied  together. 

This  state  of  the  spleen  is  generally  considered  as 
scirrhus  ;  but  its  structure  is  not  similar  to  scirrhus 
in  other  parts  of  the  body  ;  and  its  real  nature  is  prob- 
ably at  present  not  fully  understood.  When  the 
spleen  is  in  this  state,  water  is  sometimes  accumula- 
ted in  the  cavity  of  the  abdomen. 

i 
Tubercles  in  the  Spleen. 

The  spleen  is  sometimes,  although  rarely,  stud- 
ded in  its  substance  with  small  tubercles,  very  simi- 
lar to  the  scrofulous  tubercles  of  the  lungs.  In  one 
instance  I  have  seen  some  of  these  in  a  state  of  sup- 
puration, and  the  pus  was  thick  and  curdly,  like  scrof- 
ulous pus. 


Coats  of  the  Spleen  Cartilaginous. 

The  coats  of  the  spleen  are  sometimes  converted 
into  cartilage  ;  and  this  disease  ma\  be  considered  in 
a  great  measure  as  peculiar  to  the  spleen.  It  is,  at 
least,  much  more  common  in  this  viscus  than  in  any 
ether. 


[     158     ] 

The  cartilage  is  generally  to  be  found  on  the  convex 
surface  of  the  spleen,  and  extends  over  more  or  less 
of  it,  in  different  cases.  It  is  much  thicker  in  one 
case  than  another:  in  some  being  no  thicker  than  a 
shilling,  and  in  others  being  four  times  as  thick.  It 
is  generally  formed  in  a  smooth  la}  er,  but  occasion- 
ally it  is  somewhat  irregular.  I  have  also  seen,  in 
some  instances,  small  spots  of  cartilage  over  the 
whole  surface  of  the  spleen.  It  would  appear  that 
ossifications*  are  sometimes  to  be  found  in  this  car- 
tilage, but  in  the  cases  which  have  come  under  my 
©wn  examination,  bony  matter  was  not  to  be  ob- 
served. The  cartilage  into  which  the  coats  of  the 
spleen  are  changed,  does  not  resemble  the  cartilage 
at  the  extremities  of  the  bones,  but  more  that  of  the 
nose  and  ears,  although  it  is  generally  of  a  whiter 
colour.  This  diseased  process,  it  is  natural  to  think, 
is  slow  in  its  progress,  can  hardly  produce  any  im- 
pediment to  the  functions  of  the  spleen,  and  is  prob- 
ably not  marked  by  any  peculiar  feelings  to  the  pa- 
tient. 


Spleen  very  large. 

The  spleen  is  sometimes  found  to  be  much  larger 
in  its  size  than  natural,  but  with  a  structure  perfect- 
ly healthy  ;  and  this  more  commonly  happens  to  the 
spleen  than  to  any  other  viscus.  Although  it  may  be 
loolved  upon  as  a  monstrous  growth  of  the  spleen, 
rather  than  a  disease,  yet  it  may  produce  inconven- 
ience by  its  pressure,  and  by  altering  in  some  degree 
the  situation  of  the  neighbouring  viscera. 


IT// dat Ids  in  the  Spleen. 
Hydatids  are  occasionally   found    in  the  spleen,f 

M&rgagni   has  seen   ossification  of  a  part  of  the  cap:u!«?  of  the  spleen. 
Vid.  Epist    X.   Art.  19    Epist.  XIV.  Art.  &3l 
t  Vid.  Morgagni,  Epist.  XXXVIII.  Art.  34. 


[     159     ] 

which  are  of  the  same  kind  with  those  of  the  liver  ; 
but  they  are  much  more  common  in  the  latter  viscus, 
than  in  the  former. 


Stony  Concretions  in  the  Spleen. 

Stony  concretions*  have  been  seen  occasionally  in 
the  spleen  ;  but  such  cases  are  very  rare,  and  have 
«ot  fallen  under  my  own  observation. 

The  Spleen  ruptured. 

The  spleen  has  been  known  sometimes  to  be  rup- 
tured, in  consequence  of  external  pressure  upon  that 
side  of  the  body  where  it  is  situated.  When  the  spleen 
is  of  the  common  size,  an  accident  of  this  kind  can 
very  rarely  take  place,  because  it  is  well  defended  by 
the  ribs  of  the  left  side  ;  but  when  the  spleen  is  very 
large,  so  that  a  part  of  it  passes  below  the  margin  of 
the  ribs  into  the  cavity  of  the  flank,  such  an  accident 
may  very  readily  happen. 


Several  small  Spleens. 

There  is  a  variety  in  the  natural  formation  of  the 
spleen,  which  I  believe  does  not  take  place  in  that  of 
any  other  gland  in  the  body.  It  consists  in  several 
small  spleens  being  formed  besides  the  common  one. 
They  vary  in  their  size  in  different  instances,  but  I 
have  seen  some  of  them  as  large  as  a  walnut.  They 
are  situated  in  the  omentum,  near  the  great  end  of  the 
stomach  are  supplied  with  blood  vessels  from  the 
splenic  artery  and  vein,  and  have  exactly  the  same 
structure  as  a  common  spleen.  It  will  probably  make 
no  difference  with  regard  to  the  use  of  the  spleen, 

•  Vii.  Lieutaud,  Tom.  I.  p.  231. 


[     160     ] 

whether  it  be  entirely  formed  of  one  mass,  or  wheth- 
er it  consists  of  several  distinct  parts. 


Spleen  said  to  be  %v  anting. 

The  spleen  has  been  said  to  be  occasionally  want- 
ing as  a  defect  in  the  natural  formation,  but  this  too  is 
very  uncommon.*  We  know  that  an  animal  is  capable 
not  only  of  existing,  but  also  of  enjoying  good  health 
without  a. spleen.  The  spleen  has  been  cut  out  by 
way  of  experiment,  from  some  quadrupeds,  and  they 
did  not  appear  to  suffer  any  inconvenience  from  the 
want  of  it.  The  human  spleen  has  even  been  remo- 
ved in  a  few  instances,  and  the  persons  have  not  only 
recovered;  but  have  enjoyed  afterwards  good  health. 
It  does  not  appear,  therefore,  very  wonderful  that 
a  body  should  be  formed  without  a  spleen,  and  carry 
on  its  vital  functions  without  any  obvious  imperfec- 
tion. 


SYMPTOMS. 


When  inflammation  attacks  the  coats  of  the  spleen, 
it  is  attended  with  the  same  symptoms  as  an  inflam- 
mation of  that  portion  of  the  peritoneum,  which  lies 
in  the  left  hypochondrium!  There  is  pain  in  that  re- 
gion, which  is  more  or  less  acute  according  to  the  de- 
gree of  the  inflammation  ;  and  this  pain  is  ericreased 

*  Vid.  Lieutaud,  Tern.  I.  p   234. 


C     161     ] 

upon  pressure.     If  the  inflammation  be  considerable, 
it  is  accompanied  with  symptomatic  fever. 


The  symptoms  which  have  been  described  asbe- 
Iongingto  inflammation  of  the  substance  of  the  spleen, 
arc  a  fullness  and  sense  of  pain  in  the  left  hypochon- 
drium.  The  pain  is  increased  upon  pressure,  and 
there  is  more  or  less  of  symptomatic  fever.  In  two 
cases  of  inflamed  spleen,  examined  by  the  late  Dr. 
Hunter,  where  the  inflammation  had  advanced  to  sup- 
puration, the  patients  could  not  define  accurately  the 
seat  of  their  pain,  but  the  pain  seemed  to  travel  a  good 
deal  over  the  general  cavity  of  the  abdomen. 


An  enlarged  and  hardened  state  of  the  spleen  is  not 
suspected  or  known  till  the  disease  has  made  a  consid- 
erable progress,  so  that  the  spleen  is  capable  of  being 
felt  externally.  It  is  commonly  attended  with  no  pain , 
and  will  even  bear  a  pretty  strong  pressure,  without 
any  painful  sensation.  It  may  be  distinguished  when 
the  spleen  has  arrived  at  a  considerable  size,  by  the 
situation  and  the  general  shape  of  the  tumour.  The 
anterior  edge  of  the  spleen  can  generally  be  felt  dis- 
tinctly by  the  hand  applied  to  the  surface  of  the  ab- 
domen, under  the  margin  of  the  ribs  upon  the  left 
side  ;  and  the  edge  is  sometimes  distinguished  by 
this  examination  to  be  notched.  This  state  of  the 
spleen  is  often  at  length  attended  with  dropsy. 


There  are  no  peculiar  symptoms  which  character- 
ize the  formation  of  hydatids  in  the  spleen.  A  pain 
has  been  remarked  to  be  felt,  in  such  cases,  in  the 
left  hypochondriumj  but  this  also  belongs   to  many 

W 


[     1G2     ] 

other  complaints.  When  a  swelling  begins  in  the 
situation  of  the  spleen,  and  spreads  very  slowly  into 
the  cavity  of  the  abdomen,  being  somewhat  soft  to 
the  feeling,  and  perhaps  giving  some  obscure  sense 
of  fluctuation,  the  disease  may  then  be  reasonably 
supposed  to  depend  on  the  formation  of  hydatids  la 
this  organ. 


[      163     ] 


CHAP.  XII. 


DISEASED     APPEARANCES    OF  THE   PANCREAS* 

J_  HE  pancreas  is  subject  to  very  few  diseases. 
It  seldom  happens,  upon  examining  dead  bodies,  that 
it  exhibits  any  other  than  the  healthy  structure. 

Abscess  of  the  Pancreas. 

Inflammation  is  very  little  apt  to  affect  the  pancre- 
as. It  has  only  occurred  to  me  to  see  one  instance  of 
an  abscess  formed  in  it.  It  was  a  good  deal  enlarged 
in  its  size,  and  contained  a  considerable  quantity  cf 
thin  pus. 

Pancreas  hard* 

It  is  not  very  uncommon  to  find  the  pancreas  much 
harder  than  in  its  natural  state,  and  at  the  same  time 
■it  is  thicker  and  shorter  than  usual.  There  is,  how- 
ever, little  appearance  to  the  eye  of  its  structure  be- 
ing altered.  This  I  believe  to  be  the  beginning  of  a 
process,  by  which  the  pancreas  becomes  truly  schir- 
rhus.  It  very  seldom  in  this  state  shews,  in  any 
part,  the  real  schirrhus  structure.  But  I  have  seen 
this  to  be  the  case  which  renders  it  very  probable, 
that  the  one  is  the  beginning  of  a  change  into  the  oth- 
er. When  the  pancreas  in  any  part  assumes  the 
scirrhus  structure,  that  part  loses  entirely  its  natural 
appearance,  and  is  converted  into  a  hard,  uniform, 
white  mass,  somewhat  intersected  by  membrane, 
like  scirrhus  in  other  parts  of  the  body.  In  some 
cases  it  has  been  observed,  in  this  state,  to  be  consid- 
erably enlarged. 


[     164     ] 


Calculi  of  the  Pancreas. 

Calculi  are  occasionally  formed  in  the  ducts  of  the 
pancreas.  Of  this  I  have  known  only*  one  instance. 
The  calculi  were  about  the  size  of  the  kernel  of  aha* 
zle  nut,  with  a  very  irregular  surface,  and  of  a  white 
colour.  These  stones  dissolved  in  marine  acid  with 
the  extraction  of  a  large  quantity  of  carbonic  gaz,and 
are  found  to  consist  of  carbonated  lime.*  It  is  not 
improbable  that  calculi  formed  in  the  pancreas  may 
differ  somewhat  from  each  other,  as  we  find  to  hap- 
pen in  other  calculi  which  are  formed  in  the  body  j 
but  as  this  is  a  very  rare  disease  in  the  pancreas,  it 
must  be  a  longtime  before  this  point  can  be  fully  as* 
certained. 

Pancreas  wanting. 

The  pancreas  has  been  said  to  be  entirely  wanting, 
as  a  defect  in  the  original  formation,  t 


SYMPTOMS. 

I  have  only  had  one  opportunity  of  seeing  an  ab* 
scess  ill  the  pancreas.  It  was  in  a  young  man,  a  little 
beyond  the  age  of  twenty.  He  did  not  complain  of 
any  fixed  pain  in  the  situation  of  the  pancreas,  but 
had  a  good  deal  of  pain  in  different  p«:rts  of  the  abdo- 
men. This  seemed  to  be  connected  with  spasmodic 
contractions  of  the,  intestinal  canal,  which  inclosed 
portions  of  wind,  and  also  with  spasms  of  the  abdom- 
inal muscles.  There  was  sickness  <  nd  distention 
of  the  stomach  more  especially  after  eating,  and  the 
food  likewise  sometimes  occasioned  a  sense  ofweip;ht 
in  that  organ.  He  had  a  disposition  to  purging  ; 
made  but  little  water  ;  and  became  at  length  dronsi- 


•   See  Dr.  Pemberton's  Treatise  upon  the-  Abdominal  Viscera,  p.  92. 
f  Vid  Lieutaud,  Tom.  I,  J>.  24?". 


[      1G5     ] 

tal.  His  pulse  was  commonly  about  eighty.*  In 
some  cases  which  are  related  in  books,  I  find  that  pa- 
tients with  abscesses  in  the  pancreas  have  commonly 
complained  of  pain  in  the  back  and  lotus,  but  thee 
seem  to  have  had  no  peculiar  symptoms. 


When  the  pancreas  becomes  harder  than  in  its 
healthy  state,  it  is  often,  I  believe,  not  attended 
with  any  painful  sensations  to  the  patient  which  are 
strongly  marked  lint  it  sometimes  happens,  al- 
though rarely,  that  the  pancreas  becomes  much  en- 
larged in  its  size,  as  well  as  hard  in  its  structure,  un- 
dergoing these  changes  which  belong1  to  seirrhus. 
In  such  cases,  a  long  continued  pain  has  been  remark- 
ed to  exist  in  the  epigastric  region,  and  the  stom- 
ach has  been  affected  with  sickness.  In  one  instance, 
of  which  I  have  heard  an  account,  besides  the  symp- 
toms already  mentioned,  there  was  a  pain  In  the  hips, 
and  a  sense  of  numbness  in  one  thigh  and  leg. 


I  am  not  acquainted  with  the  symptoms  which  arc 
produced  by  the  formation  of  calculi  in  the  pancreas. 
If  the  calculi  should  happen  to  be  smooth,  and  few 
in  number,  they  would  probably  occasion  little  pain 
or  inconvenience.  But  if  they  should  be  rough  upon 
their  surface  and  numerous,  they  would  probably 
produce  a  good  deal  of  irritation  and  pain  in  the  pan- 
creas ;  but  it  is  not  likely  that  -ve  should  be  able  to 
guess  at  the  cause  of  the  irritation,  unless  some  of 
the  calculi  having  passed  into  the  duodenum,  should 
be  evacuated  by  vomiting,  or  by  stool. 


*  7 or  the  account  of  the  symptoms  in  the  above  case,  I   ;m  indebted  to 
Dr.  Win,   iioiberdeu. 


[     1-66     ] 


CHAP.  XIII. 


DISEASED     APP£ARAVCES     OF     THE     KIDNEYS    AND 
THE   11ENAL  CATSULtS. 


Capsule  of  the  Kidneys  inflamed. 


i 


DO  not  recollect  to  have  seen  the  proper  capsule 
of  the  kidney  inflamed,  and  I  am  disposed  to  consid- 
er it  as  a  rare  morbid  appearance.  The  reason,  prob- 
ably, why  it  seldom  occurs,  is  that  the  periton  ■  um 
reflected  over  the  surface  of  the  kidney  has  a  very 
loose  connection  with  it,  there  being  interposed  be- 
tween them  a  considerable  quantity  of  cellular  mem- 
brane and  fat.  It  seems  very  likely  that  the  princi- 
pal reason  why  the  capsules  of  some  other  glands  in 
the  abdomen  are  so  frequently  inflamed,  is  their  close 
connection  with  the  peritoneum;  which  membrane, 
from  circumstances  it  is  perhaps  difficult  to  ascertain, 
is  very  liable  to  inflammation.  When  the  capsule  of 
the  kidneys  is  inflamed,  the  same  appearances  of  in- 
flammation will  take  place  which  have  been  so  often 
noted. 


Abscesses  of  the  Kidneys. 

When  the  substance  of  the  kidneys  is  inflamed,  it 
frequently  advances  to  suppuration,  and  perhaps 
there  is  no  considerable  gland  in  the  body  so  liable  to 
form  abscesses  as  the  kidneys.  In  some  casts  which 
I  have  seen,  the  abscesses  have  appeared  to  be  of  a 
common  nature  ;  but  in  the  greater  number  of  cases 
they  have  been  scrofulous. 


C     167     ] 

When  a  kidney  is  attacked  with  scrofula,  and  the 
disease  has  advanced  to  suppuration,  it  exhibits  dif- 
ferent appearances,  according  to  the  degree  of  the  ad- 
vancement. Sometimes  there  are  only  one  or  two 
circumscribed  abscesses,  containing  a  curdly  pus, 
without  any  thing  being  particularly  observable  in  the 
inner  surface  of  the  abscesses.  Frequently,  howev- 
er, the  inner  surface  of  the  abscesses  is  lined  with  a 
pulpy  matter.  These  abscesses  generally  first  des- 
troy the  mamillary  portion  of  the  kidney  ;  and  when 
they  advance  very  far,  they  destroy  almost  the  whole 
structure  of  the  kidney,  converting  it  into  capsules 
which  surround  a  number  of  imperfect  cavities  that 
are  lined  with  this  pulpy  substance. 

The  capsule  into  which  a  kidney  is  changed  by  the 
progress  of  this  disease,  is  on  some  occasions  thick- 
er than  on  others,  frequently  of  considerable  hard- 
ness, and  seems  sometimes  to  be  slightly  laminated. 
When  a  kidney  is  so  affected,  it  is  not  uncommon 
for  the  pelvis  and  ureter  to  partake  of  the  disease, 
and  a  calculus  is  often  found  either  in  the  abscess,  or 
in  the  pelvis  of  the  ureter. 


Scr'ojitlous  Tubercles  in  the  Kidneys. 

It  is  not  unusual  (as  we  have  stated  above)  for 
scrofulous  abscesses  to  take  place  in  the  kidneys,  but 
it  occurs  very  rarely  that  scrofulous  tubercles  are 
formed  in  them.  I  have  seen,  however,  an  instance  of 
this  kind,  and  the  tubercles  resembled  most  exactly 
the  common  tubercles  of  the  lungs.  None  of  them 
were  in  a  state  of  suppuration. 


•  In  such  cases,  it  is  very  probable  that  the  calcujrs  is  th?  immfcliat-  cat<s» 
of  the  other  disease,  the  constitution  bang  at  the  nm*.  time  di'-pojed  to  it. 
By  the  irritation  of  the  calculus,  inflammation  and  suppuration  are  produced 
is  the  kidney,   and  these  partake  of  the  nature  of  the  constitution, 


C     168     3 


Kidney  Scirrhus. 

The  kidney  I  have  once  seen  converted  into  a  firm, 
uniform  substance,  somewhat  intersected  by  mem- 
brane, in  which  the  natural  structure  of  this  gland 
was  entirely  lost.  The  kidney  was  at  the  same  time 
very  much  enlarged  in  size.  This  alteration  of  struc- 
ture I  should  call  scirrhus,  because  it  exactly  resem- 
bles scirrhus  in  other  parts  of  the  body  :  it  occurs 
very  rarely  in  the  kidneys. 

State  of  the  Kidneys  in  Diabetes, 

Opportunities  do  not  frequently  occur  of  examin- 
ing the  state  of  the  kidneys  in  diabetes.     I  have  once, 
however,  been  able  to  make  this  examination  in  a  sat- 
isfactory manner,    where  a  person  had  been  long  af- 
fected with  diabetes    and  had  been  a   patient   under 
my  care  at  St.  George's  Hospital.     In  both  kidneys 
the  superficial  veins  were  much  fuller  of  blood  than 
usual,  forming  upon  their  surface  a  most   beautiful 
network  of  vessels.     The  whole  substance  of  the  kid- 
neys was  much  more  vascular  than  in  a  healthy  state, 
approaching  a  good  deal  in  appearance  to  what  takes 
place  in  inflammation.     In  both  of  them  there  was  a 
very  small  quantity  of  a  whitish  fluid,  somewhat  re- 
sembling pus  ;  but  there    was  no   appearance  of  ul- 
ceration whatever.     The  artery,  the  vein,  the  lym- 
phatic vessels,  and  the  nerves  of  both  kidneys  were 
in  their  natural  state.     The  liver,  at  the  same  time, 
I  examined  with  care,  because  it  has  bepi  thought  by 
some  to  be  the  chief  source  of  disease  in  diabetic  pa- 
tients, but  it  was  perfectly  sound.     The  stomach  and 
intestines  were  also  examined  with  attention,  but  no 
appearances  occurred   in  them  which   are  not  very 
co mm  or.. 


[     169     ] 

Kidneys  very  soft. 

I  have  also  seen  the  substance  of  the  kidney  con- 
verted into  a  soft  loose  mass,  resembling  almost  ex- 
actly the  appearance  of  common  sponge.  On  the 
surface  there  were  many  round  interstitial  cavities 
scattered  at  irregular  distances  ;  and  when  the  sub- 
stance of  the  kidney  was  cut  into,  it  exhibited  the 
same  spongy  structure.  The  blood  vessels  of  the 
kidney  were  seen  ramifying  very  distinctly  through 
the  spongy  mass.  There  was  no  appearance  of  pus 
in  the  kidney,  nor  was  there  the  most  distant  resem- 
blance between  this  process,  and  the  effects  produ- 
ced by  suppuration.  It  was  a  process  of  a  peculiar 
kind,  by  which  a  considerable  portion  of  the  kidney 
was  removed  by  the  action,  probably,  of  absorbent 
vessels,  and  it  seemed  to  act  much  more  on  the  cor- 
tical than  the  tubular  part  of  it.  I  am  not  at  all  exag- 
gerating the  effect  of  this  diseased  process  when  I  say, 
that  the  kidney  was  rendered  fully  as  soft  as  a  com- 
mon sponge.  When  shaken  in  water,  the  parts  all 
separated  from  each  other,  somewhat  like  the  unrav- 
elling of  the  shaggy  vessels  of  the  placenta.  Such 
an  appearance  of  kidney,  but  in  a  much  smaller  de- 
gree, has  fallen  two  or  three  times  under  my  obser- 
vation. 


Hydatids  of  the  Kidneys. 

The  formation  of  hydatids  is  not  an  uncommon 
disease  in  the  kidneys.  There  arc  sometimes  one 
or  two  considerable  hydatids  on  the  surface  of  the 
kidney,  lying  between  its  substance  and  capsule  ;  at 
other  times,  they  are  more  numerous.  These  hyd- 
atids do  not  appear  to  be  of  the  same  nature  with  the 
hydatids  of  the  liver  :  they  are  not  inclosed  in  firm 
cysts  ;  their  coats  are  also  thinner,  and  less  pulpy  ; 
X 


[      170     J 

and  not  uncommonly  they  arc  almost  as  thin  as  any 
membrane  of  the  body.  I  do  not  recollect  to  have 
seen  any  instance  of  small  hydatids  of  this  sort  attach- 
ed to  the  coats  of  larger  hydatids  in  the  kidney,  as 
may  be  frequently  observed  in  the  liver.  It  is  there- 
fore probable,  that  the  hydatids  which  are  commonly 
found  in  the  kidney,  depend  on  a  diseased  alteration 
of  the  structure  of  this  organ,  and  are  not  distinct  or- 
ganized simple  animals. 

Sometimes,  however,  the  true  hydatid  is  formed 
in  the  kidneys,  having  exactly  the  same  nature  w  ith 
that  which  grows  in  the  liver.  It  has  occurred  to  me 
to  be  able  to  examine  particularly  a  case  of  this  kind 
after  death,  and  I  shall  describe  at  some  length  what 
came  under  my  observation.  The  right  kidney,  in 
a  soldier,  was  converted  into  a  bag  capable  of  contain- 
ing at  least  three  pints  of  fluid,  and  only  a  very  small 
part  of  the  kidney  at  the  lower  end  retained  its  natural 
structure  The  bag  was  of  considerable  thickness, 
was  obscurely  laminated,  and  had  a  cartilaginous 
hardness  upon  its  inner  surface.  It  was  full  of  hy- 
datids, which  differed  very  much  from  each  other  in 
their  size,  some  of  them  being  as  large  as  a  small  or- 
ange, and  others  not  larger  than  the  head  of  a  pin. 
Some  of  the  small  hydatids  werelodged  in  little  cavities 
formed  in  the  inner  surface  of  the  bag.  Their  coats 
were  in  general  easily  separable  into  two  laminae,  and 
varied  a  good  deal  in  thickness  in  different  hydatids. 
This  difference  made  one  hydatid  look  opaque,  while 
another  was  transparent.  Even  in  the  same  hydatid 
there  was  often  a  difference  in  the  opacity,  or  trans- 
parency of  its  coat  at  different  parts.  Some  hydatids 
had,  adhering  to  their  inner  surface,  a  cluster  of 
small  hydatids,  which  looked  like  small  pearls  ;  others 
had  hydatids  even  of  a  considerable  size  floating  loose 
in  their  cavity;  and  ethers  contained  only  a  fluid. 
The  fluid  in  many  was  transparent,  but  in  some  hy- 
datids it  resembled  whey.  Some  of  the  small  hyda- 
tids had  frequently  been  passed  along  with  the  urine, 
when  the  person  was  alive.     It  required  an  increased 


t  1-1  ] 

exertion  of  the  muscular  power  of  the  bladder  to  &fi 

them  through  the  urethra,  and  the    bladder,  by    1 1 1 : - 
exertion  acquired  a  stronger  muscular  coat,  as  in  other 
oases  of  obstruction  to  the  free  passage  of  the  urin 


Calculi  of  the  Kidneys. 

The  formation  of  calculi  is  not  peculiar  to 
neys,  but  it  is  a  more  frequent  disease  in  them  than 
in  any  other  part  of  the  body.  Small  granules  of 
stone  are  sometimes  found  in  the  tubular  p<  rtion  of 
the  kidneys;  but  it  is  more  common  to  find  a  calculus 
of  considerable  size  lodged  either  in  some  part  of 
substance  of  the  kidney,  or  in  the  pelvis  of  the  ureter. 
The  last  situation  is  by  much  the  most  frequent. 
When  a  stone  in  this  situation  is  so  large  as  not  to  be 
capable  of  passing  through  the  ureter,  it  is  afterward* 
gradually  increased  in  size,  from  the  contact  of  the 
mine.  In  itsgrowth,  it  necessarily  follows  the  bran- 
ches of  the  pelvis,  which  are  called  infundibula,  and 
is  therefore  of  an  arborescent  form.  Such  calculi  va- 
ry in  their  colour  and  surface  ;  they  are  sometimes  o! 
a  light  brown,  sometimes  of  a  dark  brown,  and  some- 
times of  a  white  colour.  Tlvey  are  also  sometimes 
smooth,  and  sometimes  a  little  roughened  on  their  sur- 
face.  Of  the  nature  of  urinary  calculi  we  sball 
.k  afterwards,  when  we  come  to  take  notice  <  f 
the  diseased  appearances  of  the  bladder.  When  ;.. 
stone  iii  the  pelvis  of  the  ureter  has  increased  to 
a  very  considerable  size,  it  almost  entirely  j 
vents  the  urine  from  passing  into  the  ureter.  The 
urine  is  therefore  accumulated  in  the  pelvis  above 
the  stone,  and  hence  enlarges  the  pelvis  very  much 
as  well  as  the  cavity  in  the  kidney  itself.  From 
the  pressure  too  of  the  urine  behind  the  stone, 
the  pelvis  of  the  ureter,  besides  being  enlarged,  i- 
thrust  out  from  the  substance  of  the  kidney.  If  the 
interruption  to  the  passage  of  the  urine  from  the  kid- 
ney arises  from  some  obstruction  in  the  lower  < 
lity  of  the  ureter,  or  at  the  neck  b!add<  i 


[     172     ] 

or  in  any  part  of  the  urethra,  not  only  the  pelvis  of 
the  ureter  is  then  enlarged,  but  the  ureter  itself.  I 
have  seen  the  ureters  of  both  kidneys  enlarged  from 
this  cause  to  twice  or  thrice  their  natural  size. 

Whatever  be  the  nature  of  the  obstruction,  if  the 
pelvis  of  the  ureter  be  very  much  enlarged  from  the 
accumulation  of  the  urine,  the  cavity  of  the  kidney  is. 
at  the  same  time  enlarged.  As  this  process  advances, 
the  substance  of  the  kidney  becomes  more  and  more 
compressed,  is  gradually  absorbed,  and  its  cavity  be- 
comes enlarged  in  proportion.  The  substance  of  the 
kidney  is,  at  length,  in  a  great  measure  lost,  and  is 
converted  into  a  capsule,  containing  a  great  many 
cells,  which  communicate  with  each  other.  The 
capsule  is  sometimes  very  thin,  and  the  whole  mass 
a  great  deal  larger  than  the  natural  size  of  a  healthy 
kidney.  It  is  worthy  of  remark,  that  the  urine  is  se- 
creted even  when  the  natural  structure  of  the  kidney 
is  almost  entirely  lost.  This  is  seen  both  in  the  de- 
rangement of  the  kidneys  now  under  consideration, 
and  when  they  are  converted  into  a  mass  of  hydatids. 
It  would  appear  from  this  fact,  that  a  very  small  por- 
tion of  the  natural  structure  of  the  kidneys  is  capable 
of  secreting  very  nearly  the  ordinary  quantity  of  the 
urine. 

Kidneys  earthy  and  bony. 

The  kidneys  have  been  said  to  be  converted  into 
an  earthy  substance.*  A  kidney  has  also  been  known 
to  become  ossified,  f  Such  appearances  have  never 
come  under  my  own  observation,  and  I  am  persua- 
ded are  extremely  rare. 

Original  Varieties  in  the  Kidneys. 

The  kidneys  are  subject  to  a  good  deal  of  variety 
in -.heir  natural  circumstances,  from  original   forma- 

*    Vid    Lieutaud,  Tom.  I.  j>.  'A  2. 

\  See  Medical  Conamunifcations,  Vol.  I.  p.  416. 


[    m   ] 

tion.  The  two  kidneys  are  sometimes  found  to  be 
joined  together  :  they  arc  sometimes  situated  before 
the  lumbar  vertebra:,  and  sometimes  on  the  sides  of 
the  pelvis.  They  are  occasionally  very  small  in  their 
size,  and  the  kidney  on  one  side  is  sometimes  want- 
ing ;  when  this  is  the  case,  the  other  kidney  is  lar- 
ger than  the  ordinary  size. 

It  is  very  difficult  to  assign  a  satisfactory  reason 
why  there  should  be  such  variety  in  the  kidneys  ; 
but  we  can  sec  that  there  is  little  disadvantage  to  the 
animal  functions  produced  by  this  variety. 

The  kidneys  arc  not  large  in  their  size,  and  there- 
fore may  be  changed  in  their  situation  without  any 
sensible  inconvenience.  As  their  function  is  inde- 
pendent of  relative  situation,  it  must  be  precisely  the 
same  wherever  the  kidneys  are  placed. 

When  the  kidneys  are  small,  the  secretion  of  the 
urine  may  be  very  nearly  in  the  common  quantity, 
from  a  greater  activity  in  carrying  on  their  function  ; 
or  such  persons  may  be  disponed  to  sweat  more  than 
usual,  to  counterbalance  the  deficiency  of  the  urine. 
We  know  very  well  that  the  secretions  of  the  sweat 
and  the  urine  are  vicarious.  When  a  kidney  is  want- 
ing, the  other  being  of  a  large  size  is  probably  capa- 
ble of  doing  the  office  of  two  kidneys. 


Diseased  Appearances  of  the  Renal  Capsules. 

The  renal  capsules  are  scarcely  ever  found,  diseased. 
The  dark  coloured  substance  in  their  centre,  which 
naturally  has  some  consistence,  is  occasionally  very 
soft,  so  as  almost  to  be  fluid.  This  is  probably  what 
is  meant  by  authors,  when  they  say  that  they  have 
found  in  the  cavity  of  the  renal  capsules  a  fluid  like 
ink.  Their  description  may  be  considered  as  being 
a  little  exaggerated. 


[     174     ] 

Abscess  in  the  Renal  Capsules. 

The  renal  capsules  are  very  seldom  attacked  with 
inflammation,  and  therefore  abscesses  have  very  rare- 
ly occurred  in  them.  There  is  much  variety  in  the 
different  parts  of  the  body,  with  regard  to  their  sus- 
ceptibility of  being  excited  to  inflammation.  A  few 
cases  of  abscesses  in  the  renal  capsules  are  related  by 
authors. 

Renal  Capsule  scrofulous. 

It  has  occurred  to  me  to  see  only  one  instance  of 
scrofula  in  the  renal  capsules.*  In  this  case,  the  renal 
capsule  affected  .by  it  was  very  much  enlarged  in  its 
size,  being  nearly  as  large  as  a  kidney,  and  was  chang- 
ed into  the  same  kind  of  white  matter  which  is  ob- 
servable in  a  srofulous  absorbent  gland. 

The  renal  capsules  have  also  been  observed  to  be 
changed  into  a  cartilaginous  substance,  but  this 
morbid  appearance  occurs  very  rarely. 

Little  granules  of  stone  have  been  found  in  the 
substance  of  the  renal  capsules,  t 

SYMPTOMS* 

When  the  kidneys  are  inflamed,  more  or  less  pain 
is  felt  in  the  situation  of  these  glands,  and  the  pain 
commonly  shoots  along  the  course  of  the  ureters. 
There  is  a  sense  of  numbness  in  the  thigh,  and  in  the 
male  there  is  often  a  retraction  of  the  testicle,  or  a 
feeling  of  pain  in  it.  When  one  kidney  is  affected, 
these  symptoms  are  only  felt  upon  that  side.  The 
urine  is  voided  frequently,  and  sometimes  of  a  pale, 
but  more  commonly  of  a  deep  red  colour.  The 
stomach  sympathizes  with  this  state  of  the  kidneys, 
for  it  is  affected  with  sickness  and  vomiting  :  the 
bowels  are  at  the  same  time  often  costive,  and  sub- 
ject to  colicky  pains.  These  sensations  arc  ace: 
panied  with  more  or  less  of  symptomatic  fever. 

*  See  Soemn.'et ring's  German  Translation,  p,   172. 

i  Vid.  LkiUiuiJ,  Tom-  I.  p.  ~~6- 


E      H5     ] 

When  pus  is  formed  by  the  progress  of  the  inflam, 
mation,  it  may  be  known  by  its  being  mixed  with  the 
urine,  and  this  will  be  more  distinctly  marked  in 
proportion  to  the  quantity  of  the  pus. 


The  symptoms  which  belong  to  a  scirrhous  state 
of  the  kidneys  are  unknown  to  me,  and  I  do  not  find 
that  they  are  distinctly  marked  by  authors. 


There  would  seem  to  be  no  particular  symptoms 
which  belong  to  the  formation  of  hydatids  in  the  kid- 
ney s.  Pain  is  commonly  felt  in  the  loins  during  their 
formation  ;  there  has  been  remarked  to  be  sympto- 
matic fever,  nausea,  and  vomiting  ;  but  these  symp- 
toms belong  also  to  some  other  diseases.  This  dis- 
ease, therefore,  can  only  be  ascertained  by  hydatids 
passing  occasionally  through  the  urethra  along  with 
the  urine.  In  such  cases,  there  must  sometimes  be 
a  difficulty  in  making  water,  from  a  hydatid  inter- 
rupting the  passage  of  the  urine,  either  at  the  neck 
of  the  bladder,  or  in  some  part  of  the  urethra. 


The  symptoms  which  are  produced  by  calculi  irri- 
tating the  kidneys  correspond  very  much  with  the 
.symptoms  attending  the  inflammation  of  these  organs. 
The  irritation  from  calculi,  however,  may  be  distin- 
guished from  simple  inflammation  of  the  kidneys,  by 
these  additional  symptoms,  viz.  by  red  crystals  being 
often  deposited  from  the  urine  as  soon  as  it  is  voided, 
by  blood  being  sometimes  mixed  with  the  urine,  and 
by  the  pain  of  the  loins  being  much  increased  upon 
any  jolting  motion  of  the  body. 


Diabetes  is  distinguished  by  the  urine  being  much 


increased  beyond  the  natural  quantity,  by  its  being 
more  or  less  sweet  to  the  taste,  and  of  a  colour  some- 
what resembling  whey.  There  is  great  thirst,  and 
a  voracious  appetite  for  food.  The  pulse  is  also 
somewhat  quicker  than  natural,  and  the  body  becomes 
at  length  much  emaciated. 


C     177     ] 


CHAP.  XIV. 


DISEASED     APPEARANCES   OF  THE   BLADDER. 


Inflammation  of  the  Peritoneal  Covering. 


\_  HAT  portion  of  the  peritonaeum,  which  covers 
a  part  of  the  bladder,  is  not  very  often  inflamed  by  it- 
self, but  it  partakes  of  the  inflammation  which  ex- 
tends over  the  membrane  generally.  The  appearan- 
ces accompanying  its  inflammation  have  been  alrcadv 
described.  Inflammation  of  the  peritoneal  covering 
of  the  bladder  does  not  frequently  extend  to  its  mus- 
cular coat.  The  peritonaeum  and  the  muscular  coat 
of  the  bladder,  are  but  loosely  connected  together, 
as  a  considerable  quantity  of  cellular  membrane  is 
interposed  between  them.  This  loose  connection  is 
necessary,  in  order  that  the  peritonaeum  may  be  ac- 
commodated to  different  states  of  distension  of  the 
bladder,  and  it  has  also  the  effect  of  preventing  in- 
flammation from  spreading  readily  from  the  peritonae- 
al  covering  of  the  bladder  to  its  muscular  coat. 
When  the  inflammation  subsides,  adhesions  arc  fre- 
quently left  behind,  connecting  the  bladder  more  or 
less  to  the  neighbouring  parts  ;  in  a  female,  to  the 
uterus,  and  in  a  male  to  the  rectum. 


C    ns    ] 


Inflammation  of  the  Inner  Membrane. 

The  inner  membrane  of  the  bladder  is  occasionally 
inflamed.  When  this  happens,  the  inflammation  is 
sometimes  extended  over  the  whole  cavity,  or  is 
sometimes  confined  to  a  particular  portion  of  it. 
The  portion  which  is  most  frequently  inflamed  is  that 
near  the  neck  of  the  bladder.  This  may  arise  from 
two  causes  ;  the  one  is,  that  in  this  situation,  or  near 
it,  some  obstruction  is  frequently  found  to  the  pas- 
sage of  the  urine,  which  may  produce  irritation,  and 
bring  on  more  or  less  of  inflammation  ;  the  other  is, 
that  inflammations  of  the  urethra  occasionally  extend 
some  way  within  the  cavity  of  the  bladder,  and  even 
sometimes  over  the  whole  of  it.  It  is  well  known 
that  the  inner  membrane  of  the  bladder,  in  the  dead 
body,  hardly  shews  vessels  which  are  large  enough 
to  carry  red  blood  in  its  natural  state  ;  but  when  it  is 
inflamed  it  is  crowded  with  a  prodigious  number  of 
extremely  fine  blood  vessels,  and  there  may  be  some- 
times seen  small  spots  of  extravasated  blood.  When 
the  inflammation  is  in  a  high  degree,  the  muscular 
coat  of  the  bladder  may  be  affected  ;  but  as  this  is  on- 
ly loosely  attached  to  the  inner  membrane,  the  inflam- 
mation will  not  very  readily  pass  from  the  one  to  the 
other. 

Ulcers* 

Inflammation  of  the  inner  membrane  of  the  bladder 
advances  sometimes  to  the  formation  of  pus,  and  ab- 
scesses and  ulcers  are  occasionally  produced.  These, 
when  the  inflammation  has  been  of  the  common  sort, 
exhibit  the  ordinary  appearances  which  have  often 
been  mentioned.  They  sometimes  advance  so  far  as 
to  destroy  a  portion  of  the  bladder  entirely,  and  to 
form  communications  between  it  and  the  neighbour- 
ing parts  ;  as  with  the  general  cavity  of  the  abdomen, 
with  the  rectum  in  the  male,  and  the   vagina  in  the 


C     179     ] 

iewtale.  When  the  communication  is  formed  witr. 
the  general  cavity  of  the  abdomen,  the  urine  escapes 
into  it,  producing  there  general  peritonreal  inflamma- 
tion, of  which  I  recollect  a  very  striking  example. 
When  the  communication  is  formed  with  the  vagina 
or  the  rectum,  the  urine  will  escape  by  these  passa- 
ges, producing  in  them  more  or  less  of  irritation  and 
inflammation. 

When  abscesses  take  place  in  thebladdeT,  they 
arc  produced  more  frequently  from  local  violence, 
than  from  a  previous  spontaneous  inflammation. 
One  of  the  most  common  causes  of  violence  is  the  in- 
cision of  the  bladder  in  the  operation  of  lithotomy. 
When  the  part  has  been  very  much  irritated  in  the 
operation,  or  the  constitution  is  such  that  it  is  exci- 
ted to  violent  action  by  the  common  degree  of  irrita- 
tion, an  ulcer  is  formed  at  the  lips  of  the  wound,  and 
spreads  more  or  less  into  the  cavity  of  the  bladder. 

It  sometimes  happens,  although  I  believe  very 
rarely,  that  the  whole  of  the  inner  membrane  of  the 
bladder  is  destroyed  by  ulceration,  and  its  muscular 
fibres  appear  as  bare  as  if  they  had  been  nicely  dissec- 
ted. In  the  case  where  I  recollect  this  process  to 
have  taken  place  most  completely,  the  bladder  was 
almost  filled  with  a  scrofulous  pus.  There  was  a 
curdly  white  matter  mixed  with  pus,  which  had  ex- 
actly the  same  appearance  with  that  formed  by  tin 
suppuration  of  a  scrofulous  absorbent  gland. 

Schirrlius  and  Cancer. 

From  the  contiguity  of  the  bladder  to  parts  which 
are  very  liable  to  schirrhus  or  cancer,  it  sometimes 
partakes  of  this  disease  ;  but  I  do  not  think  that  it  is 
often  singly  affected  by  it.  The  disease  on  some  oc- 
casions spreads  to  the  bladder  from  the  rectum,  and 
on  others  from  the  uterus  :  under  such  circumstan- 
ces the  bladder  becomes  very  thick  and  hard  and  ex- 
hibits the  ordinary  cancerous  structure.     Communi- 


[      180     ] 

cations  too  are  generally  formed  either  with  the  rec- 
tum, the  uterus,  or  the  vagina. 


Fungous  Excrescences. 

Sometimes  fungous  excrescences  arise  from  the  in- 
ner surface  of  the  bladder,  either  in  one  mass,  or  in 
separate  portions  Upon  examination  they  are  found 
to  consist  of  a  loose  fibrous  structure.  When  they 
are  situated  a  little  behind  the  neck  of  the  bladder, 
which  is  not  uncommonly  the  case,  they  must  pro- 
duce a  considerable  obstruction  to  the  passage  of  the 
urine.  A  stronger  action  will,  therefore,  be  required 
in  the  bladder  to  expel  the  urine,  and  its  muscular 
coat  will  be  consequently  thickened.  Accordingly 
it  is  often  found  thickened,  and  it  is  not  improba- 
ble that  even  where  the  situation  of  the  fungus  may 
not  obstruct  the  passage  of  the  urine  into  the  urethra, 
its  presence  may  still  irritate  the  bladder  so  as  to  ex- 
cite it  to  more  frequent  and  stronger  actions  than  in 
a  natural  state,  and  the  muscular  coat  may  become 
thereby  more  or  less  thickened. 

Polypus  of  the  Bladder. 

A  polypus  sometimes  grows  from  the  inner  sur- 
face  of  the  bladder  ;  but  this  morbid  appearance  oc- 
curs very  rarely.  I  have  onty  seen  one  example  of 
it,  and  in  this  instance  it  filled  up  the  greater  part  of 
the  cavity  of  the  bladder.  It  was  very  irregular  in 
its  shape,  consisting  of  various  projecting  masses,  and 
seemed  pretty  firm  in  its  texture. 


Elongations  of  the  inner  Membrane. 

I  have  also  known  the  inner  membrane  of  the  blad- 
der elongated  in  some  parts,  so  as  to  form  irregular 
processes.     These,  when  cut  into,  were  found  to  con 


I     181     ] 

sist  of  a  considerable  quantity  of  cellular  membrane, 
intermixed  with  a  little  fat.  The  process  producing 
such  an  appearance  was  probabh  a  slow  one,  and  was 
probably  also  not  attended  with  paint  If  these  elon- 
gations were  to  be  situated  at  a  distance  from  the 
neck  of  the  bladder,  they  would  probably  not  pro- 
duce any  inconvenience  ;  but  if  situated  near  the 
neck  of  the  bladder,  they  might  occasion  extreme  dif- 
ficulty in  making  water,  and  even  lay  the  foundation 
of  a  fatal  disease. 


Cysts  communicating  with  the  Bladder. 

Cysts  are  sometimes  found  connected  very  inti- 
mately with  the  bladder,  and  communicating-  with 
its  cavity.  These  in  some  instances  have  been  ob- 
served to  be  of  a  large  size,  being  perhaps  half  as 
large  as  the  usual  size  of  the  bladder  itself.  There 
is  some  difficulty  in  explaining  the  manner  in  which 
they  arc  formed.  If  we  suppose  them  to  be  formed 
in  the  cellular  membrane;  upon  the  outside  of  the 
•bladder,  it  is  extremely  difficult  to  explain  how  they 
should  communicate  with  its  cavity,  unless  by  ul- 
ceration, which  does  not  seem  to  take  place.  If  we 
suppose  them  to  be  pouches  from  the  bladder  itself,  it 
is  still  difficult,  in  some  instances,  to  explain  why 
they  should  be  formed  at  all,  and  why  they  should 
arrive  at  so  large  a  size.  The  latter  supposition, 
however,  seems  to  be  the  most  reasonable,  and  I 
am  persuaded  it  will  apply  to  the  greater  number  of 
cases  where  such  cvsts  exist. 


Muscular  Coat  Thickened. 

One  of  the  most  ordinary  changes  in  the  bladder, 
from  its  natural  structure  is  the  great  thickening  of 
its  muscular  coat.  In  a  natural  state,  the  muscular 
coat  of  the  bladder  (when  it  is  moderatelv  distended) 
consists  of  thin  layers  of  muscular  fibres,  running  in 


[      «»     ] 

■different  directions.  These  are  probably,  altogether, 
not  more  than  the  eighth  of  an  inch  in  thickness.  The 
muscular  coat  of  the  bladder,  however,  is  occasionally 
found  at  least  half  an  inch  thick.  This  arises  from 
an  additional  quantity  of  muscle  being  formed  in  con- 
sequence of  extraordinary  efforts  being  necessary  in 
the  bladder.  These  efforts  take  place  when  there  is 
any  considerable  difficulty  in  making  water,  as  hap- 
pens when  the  prostate  gland  is  a  good  deal  enlarged, 
when  there  is  a  stone  in  the  bladder,  or  when  there 
are  strictures  in  the  urethra.  It  is  usual,  therefore, 
to  find  this  thickening  of  the  muscular  coat  of  the 
bladder  when  there  is  any  of  these  diseases.  When 
the  bladder  is  thickened,  the  fasciculi  of  which  its 
muscular  coat  is  composed  become  much  larger  ;  but 
never,  or  at  least  very  seldom,  acquire  the  full  red 
colour  which  muscles  have  in  other  parts  of  the  body. 
This  is  a  deviation  from  the  general  plan  of  nature 
with  regard  to  the  increase  of  muscles  from  exercise. 
When  muscles  are  enlarged  in  size  from  exercise, 
they  also  become  of  a  deep  red  colour.  There  is  no 
other  instance  too  in  the  body,  as  far  as  I  recollect, 
of  a  muscle  being  so  much  enlarged  beyond  its  natu- 
ral size  ;  inconsequence  cf  increased  exertion,  as  the 
muscular  coat  of  the  bladder. 

Between  the  fasciculi  of  the  muscular  fibres,  little 
pouches  are  formed  by  the  inner  membrane.  This 
arises  from  the  pressure  of  the  urine  against  the  inner 
membrane  of  the  bladder,  which  is  impelled  by  the 
strong  powers  of  the  muscular  coat.  These  pouches 
are  often  large  enough  to  admit  the  end  of  the  finger, 
and  contain  occasionally  small  calculi.  The  bladder 
in  this  state  admits  of  very  little  distension,  so  that  it 
is  capable  of  containing  little  water  ;  hence  the  in- 
clination to  make  water  is  frequent,  and  frequent  ef- 
forts of  the  muscular  coat  arc  required,  which  in- 
crease more  and  more  its  thickness.  It  is  much 
more  common  to  find  this  appearance  of  the  bladder 
in  the  male  than  in  the  female,  because  in  the  latter 
there  are  fewer  causes  to  produce  it :  since  in  that  sex 


C      183     ] 

there  is  a  want  of  the  prostate  gland  altogether,  and 
the  urethra  being  short  and  wide,  obstructions  seldom 
take  place  in  it.  When  the  muscular  coat  of  the  blad- 
der has  been  thickened,  I  believe  that  it  has  been 
sometimes  mistaken  for  scirrhus. 


The  Bladder  divided  into  two  Chambers. 

The  urinary  bladder  has  sometimes  been  observed 
to  be  divided  into  two  chambers,  which  communi- 
cate with  each  other  ;  but  this  has  happened  Aery 
rarely.  I  have  not  had  an  opportunity  myself  of  ex- 
amining this  singular  disease,  but  I  have  received  an 
account  of  such  a  case  from  Dr.  Ash,  which  had 
many  years  ago  fallen  under  his  observation.  The 
upper  chamber  of  the  bladder  in  this  case  was  gener- 
ally much  distended  with  urine,  so  that  a  round  tu- 
mour could  be  easily  distinguished  by  the  touch  above 
the  pubes.  When  a  catheter  was  introduced  into  the 
bladder,  a  few  ounces  only  of  urine  came  away,  and 
the  tumour  above  the  pubes  remained  the  same  as  be- 
fore. When  the  patient  stood  up  a  quart  of  water 
sometimes  passed  away  involuntarily,  the  tumour 
very  much  subsided,  and  the  complaint  was  relieved 
for  the  time.  After  the  death  of  the  patient,  the- 
bladder  was  found  upon  examination  to  be  divided 
into  two  chambers  by  a  firm  membranous  substance,, 
and  the  aperture  of  communication  was  almost  oblit- 
erated. 

There  seem  to  me  to  be  only  two  ways  in  which  a 
division  of  the  bladder  into  two  chambers  can  happen. 
The  one  is  by  a  morbid  growth  of  the  inner  mem- 
brane, forming  a  ridge  at  some  particular  part,  and 
at  length  by  a  continuation  of  this  process,  making  a 
septum  more  or  less  complete  in  the  bladder.  1  have 
seen  the  cavity  of  the  oesophagus  very  much  narrow- 
ed at  one  part  by  a  permanent  ridge  being  formed  in 
its  inner  membrane.  Something  of  the  same  kind  I 
have  also  seen  in  a  part  of  the  small  intestines.    ^  e 


[      184     ] 

may  therefore  readily  admit  the  possibility  of  3  simi- 
lar process  taking-  place  in  the  inner  membrane  of  the 
bladder. 

Another  way  in  which  the  bladder  may  be  supposed 
capable  of  being  divided  into  two  chambers,  is  by  a 
very  strong  contraction  of  its  transverse  muscular  fi- 
bres at  some  particular  part.  This  will  be  analogous 
to  the  hour-glass  contraction  of  the  uterus  which  is 
known  occasionally  to  take  place.  When  a  complaint 
of  the  bladder  depending  upon  its  being  divided  into 
two  chambers  has  been  temporary,  it  is  reasonable  to 
suppose  that  it  has  arisen  from  the  last  cause  ;  when 
it  has  been,  permanent,  it  is  more  likely  to  have  aris- 
en from  the  first. 


Cal  uli. 

Calculi  are  not  uncommonly  found  in  the  bladder, 
and  are  confined  in  their  formation  to  no  particular 
period  of  life.  They  are  formed  in  very  young  chil- 
dren, and  also  in  persons  of  middle  and  advanced  age. 
This  disease  is  not  so  frequently  met  with  in  the  fe- 
male, as  in  the  male,  which  may  depend  on  two  causes  ; 
the  one  is  that  there  is  not  so  strong  a  tendency  to 
their  formation  in  that  sex  ;  and  the  other  cause  is, 
that  stones  escape  through  the  urethra  in  women, 
which  would  be  detained  in  the  bladder  of  men,  and 
lay  the   foundation  there  of  larger  calculi. 

The  stones  which  are  found  in  the  bladder,  are  ei- 
ther originally  formed  in  the  kidneys,  and  pass 
through  the  ureters  into  the  bladder,  or  they  are  first 
formed  in  the  bladder  itself.  When  the  latter  cir- 
cumstance takes  place,  the  earthy  matter  is  some- 
times first  deposited  round  some  extraneous  body, 
which  becomes  the  nucleus  of  the  calculus,  but  most 
frequently  no  nucleus  whatever  is  to  be  observed. 
The  nuclei,  which  I  have  seen,  have  been  small  por- 
tions of  lead  (probably  broken  off  from  a  leaden  bou- 
gie) small  nails,  and  little  masses  of  hair.     In  short, 


[     185     ] 

any  extraneous  body  which  may  happen  to  be  intro- 
duced into  the  bladder,  may  become  a  nucleus.  It  is 
natural  to  think  that  such  nuclei  are  more  common  in 
the  calculi  found  in  the  bladder  of  women  than  of  men, 
because  their  urethra  is  wider  and  shorter,  so  that  an 
extraneous  body  can  be  much  more  easily  introduced 
into  their  bladder. 

The  calculi  of  the  bladder  either  lie  loose  in  it,  or 
are  confined  to  some  fixed  situation  from  particular 
circumstances.  When  they  are  of  a  small  size,  they 
are  sometimes  lodged  in  pouches,  or  sacculi,  formed 
by  the  protrusion  of  the  inner  membrane  of  the  blad- 
ber  between  the  fasciculi  of  its  muscular  fibres.  A 
calculus  also  is  occasionally  attached  to  an  excres- 
cence of  the  bladder,  so  as  to  be  kept  in  a  fixed  situ- 
ation. 

There  is  frequently  one  calculus  only  in  the  blad- 
der at  a  time,  and  then  it  is  usually  of  an  oval  form  ; 
but  there  are  often  more,  and  the  calculi  by  rubbing 
upon  each  other  in  a  narrow  space  acquire  flat  sides 
and  angles.  Calculi  have  sometimes  a  smooth  uni- 
form surface,  but  most  frequently  the  surface  is  gran- 
ulated. These  granules  arc  commonly  placed  very 
near  each  other  over  the  whole  surface  of  the  calculus, 
giving  it  a  certain  degree  of  roughness.  They  are, 
however,  occasionally  gathered  into  clusters  on  par- 
ticular parts  of  the  surface  of  a  calculus.  These 
granules  are  sometimes  of  a  smaller,  and  sometimes 
of  a  larger  size,  and  in  different  calculi  are  more  or 
less  elevated.  Some  calculi  have  an  irregular  porous 
structure  upon  the  surface  instead  of  being  granula- 
ted. 

Calculi  when  divided  by  the  saw,  or  broken,  ex- 
hibit most  commonly  a  laminated  structure.  These 
laminae  are  disposed  in  concentric  curves,  and  are 
applied  together  with  more  or  less  compactness  :  in 
some  calculi  the  laminae  adhere  together  very  slightly. 
They  differ  in  their  thickness  indifferent  calculi  :  and 
the  laminated  structure  sometimes  pervades  uniform- 
Z 


E     186     ] 

ly  the  whole  mass  of  the  calculus  ;  while  at  other 
times  different  portions  of  it  are  interrupted  by  a 
coarse  porous  texture.  In  some  calculi  no  laminated 
structure  whatever  is  observable,  but  it  is  entirely 
porous. 

The  colour  of  calculi  varies  considerably.  They 
are  most  frequently  of  a  brown  colour,  which  is  some- 
times of  a  lighter,  and  sometimes  of  a  darker  shade. 
They  are  also  sometimes  of  a  white,  and  often  of  a 
yellowish  colour.  It  is  remarkable,  that  different 
portions  of  the  same  calculus  are  frequently  of  a  dif- 
ferent colour.  Some  laminae,  for  instance,  are  per- 
fectly white,  while  the  other  laminae  are  brown.  In 
this  sort  of  mixture,  I  have  most  commonly  found 
the  white  laminae  on  the  outside,  and  the  brown  lam- 
inae in  the  middle  ;  and  I  do  not  recollect  seeing  one 
instance  of  laminae  of  different  colours,  disposed  in 
alternate  strata. 

The  specific  gravity  of  urinary  calculi  differs  very 
considerably,  as  they  differ  a  good  deal  in  their  com- 
pactness ;  but  they  are  in  general  nearly  twice  the 
specific  gravity  of  water. 

It  is  only  within  a  few  years  that  the  chemical 
analysis  of  urinary  calculi  has  been  ascertained  with 
sufficient  accuracy,  and  they  haye  been  found  to  con- 
sist of  five  species  very  different  from  each  other. 

The  first  species  is  more  common  than  the  others, 
and  consists  of  a  particular  acid  called  lithic  acid, 
mixed  with  some  gelatinous  matter,  and  in  some  in- 
stances with  a  very  small  proportion  of  lime.  Its 
texture  is  partly  laminated  and  partly  porous.  Its 
colour  is  brown,  varying  a  good  deal  in  the  depth  of 
its  shade,  and  sometimes  with  a  very  slight  yellowish 
tinge.  The  chemical  properties  of  this  species  of 
urinary  calculi  were  first  ascertained  by  Scheele  and 
Bergman. 

The  second  species  consists  of  crystals  which  arc 
formed  by  the  combination  of  phosphoric  acid  with 
magnesia  and  ammonia  :  these  are  mixed  with  some 
phosphorated  lime,  and  generally  some  lithic  acid. 


[     187     ] 

It  is  of  a  white  colour,  is  more  irregular  in  its  shape 
than  some  of  the  other  species,  and  consists  partly 
of  a  laminated  and  partly  of  a  porous  structure.  It  is 
fusible  by  the  blow-pipe,  and  therefore  has  commonly 
been    called   the  fusible  calculus. 

The  third  species  consists  of  the  acid  of  sugar  and 
acid  of  phosphorus  united  with  lime  ;  together  gen- 
erally with  some  lithic  acid  in  the  interstices.  This 
species  is  knotted  on  its  outer  surface  somewhat  like 
a  mulberry,  and  from  this  circumstance  it  has  com- 
monly  been  called  the  mulberry  calculus.  It  is  of  a 
dark  brown  colour,  and  consists  of  an  irregularly 
laminated  structure.  The  lamina;  of  which  it  is  com- 
posed often  vary  in  their  colour,  some  of  them  being 
dark,  and  others  of  a  white  colour.  The  white  lam- 
inns  are  commonly  towards  the  outer  part  of  the  cal- 
culus, although  its  colour  be  dark. 

The  fourth  species  consists  entirely  of  phosphora- 
ted lime,  and  has  been  called  the  bone-earth  calcu- 
lus. It  is  ol  a  light  brown  colour,  and  its  laminse 
slightly  adhere  to  each  other.  For  an  accurate  anal- 
ysis of  these  three  last  species  of  urinary  calculi,  we 
are  chiefly  indebted  to  Dr.   Win.   Hyde  Wollaston. 

The  fifth  species  consists  of  carbonat  of  lime,  mix- 
ed with  a  little  animal  matter  and  water,  and  was  dis- 
covered lately  by  Mr.  Crumpton.* 

The  matter  of  calculus  in  the  bladder  is  generally 
formed  in*o  one  or  more  circumscribed  masses,  yet 
it  sometimes  happens  that  the  whole  bladder  is  filled 
with  a  substance  like  mortar.  Of  this  I  recollect  one 
striking  example  ;  the  earthy  matter  in  this  case 
could  not  be  entirely  removed  from  the  bladder  ;  but 
a  great  many  small  irregular  portions  still  adhered  to 
the  sides  of  its  cavity.  I  believe  that  this  matter  was 
of  the  same  nature  with  a  common  calculus,  because 
it  exhibited  the  same  affinities  with  the  common  acids. 
Within  the  last  three  years  I  have  met  with  another 
instance  in  which  the  matter  of  calculus  put  on  the 
appearance   and   consistence  of  mortar,  but  was   in 

*  Sec  Thompson's  System  of  Chemistry,  Vol,  4,  pige671. 


[     188     ] 

small  quantity.  It  was  connected  with  a  chronic  in- 
flammation of  the  inner  membrane  of  the  bladder,  and 
processes  of  coagnlable  lymph  attached  to  the  inner 
membrane  were  encrusted  with  the  calculous  matter. 
This  disease  had  continued  for  many  years,  and  was 
combined  with  stricture  of  the  urethra. 


Bladder  Distended. 

In  opening  dead  bodies,  the  bladder  is  occasionally 
found  to  be  very  much  distended,  and  to  occupy  the 
lower  part  of  the  cavity  of  the  abdomen.  This  might 
arise  from  some  accidental  circumstance  of  the  water 
being  accumulated,  while  the  muscular  coat  of  the 
bladder  still  possessed  its  proper  powers  ;  or  the 
muscular  coat  of  the  bladder  may  have  been  paralytic, 
and  therefore  not  capable  of  expelling  the  water.  I 
do  not  think  it  is  possible  to  discriminate  between 
these  two  different  cases  by  any  examination  after 
death,  but  they  can  always  be  ascertained  by  a  care- 
ful inquiry  into  their  history. 


Bladder  Contracted. 

The  bladder  is  also  found  contracted  to  such  a  de- 
gree as  hardly  to  have  any  cavity.  This  is  general- 
ly not  to  be  considered  as  a  disease,  but  simply  as 
having  arisen  from  a  very  strong  action  of  the  mus- 
cular coat  of  the  bladder  previously  to  death. 

The  anterior  part  of  the  Bladder  wanting. 

The  anterior  part  of  the  bladder  is  occasionally 
wanting,  and  instead  of  it  there  is  a  very  soft  vascu- 
lar flesh,  situated  externally  at  the  lower  part  of  the 
abdomen.  This  soft  vascular  flesh  is  usually  formed 
into  irregular  projecting  masses,  and  in  the  living 
body  is  covered  with  a  thick  ropy  mucus.     The  two 


[     139     ] 

ureters  open  somewhere  upon  this  vascular  flesh,  dis- 
tilling gradually  the  urine  upon  its  surface,  which  the 
mucus  is  intended  to  protect  against  the  stimulus  of 
that  fluid.  When  there  is  such  a  formation  of  the 
bladder.  I  believe  that  there  is  always  a  deficiency 
of  the  bone  at  the  symphysis  pubis,  and  also  a  mon- 
strous formation  of  some  of  the  organs  of  generation. 
This  species  of  monstrosity  I  have  described  at  large 
in  the  Medical  and  Chirurgical  Transactions.* 


The  Bladder  and  the   Rectum    communicating  from 
original  Malformation. 

Another  kind  of  monstrous  formation  in  the  blad- 
der occasionally  happens,  viz.  that  at  its  depending 
part  there  is  a  communication  between  it  and  the 
rectum,  the  latter  being  continued  into  the  former. 
Of  this  I  have  seen  one  instance,  and  it  has  been  al- 
ready taken  notice  of  when  treating  of  the  diseased 
and  preternatural  appearances  of  the  intestines. 

Part  of  the  Bladder  in  a  hernial  Sack. 

A  portion  of  the  bladder  at  its  fundus  has  been 
known  to  be  lodged  in  a  hernial  sack,  as  well  under 
Paupart's  ligament,  as  at  the  abdominal  ring;  but 
this  is  very  rare,  and  has  not  fallen  under  my  own 
observation. f 


SYMPTOMS. 


In  inflammation  of  the  bladder,  a  pain  is  felt  in  the 
perinajum,  or  above  the  pubes,  accompanied  with  a 
fulness,  or  a  swelling  there.  There  arc  frequent  at- 
tempts to  make  water,  which  is  evacuated  in  small 
quantity  and  with  great  pain  ;  or  there    is  a  total  rc- 


•  See  Med    and  Chi.  Trans,  p-  189. 
^  Sec  Pott  on  Uuptures,  p.  226< 


[     190     ] 

tctition  of  the  urine,  with  a  strong  desire  to  void  it. 
Tne  rectum  is  affected  from  its  connection  with  the 
bladder,  and  is  excited  to  tenesmus.  The  stomach 
likewise  takes  a  part  in  the  disease,  being  affected 
with  sickness  and  vomiting.  In  some  cases  there  is 
delirium.  When  pus  has  been  formed  in  conse- 
quence of  the  inflammation,  it  is  known  by  being  mix- 
ed with  the  urine  which  is  evacuated. 


When  the  bladder  has  become  affected  by  an  ulcer 
spreading  to  it  from  the  neighbouring  parts,  it  may 
be  suspected  by  the  pain  and  difficulty  which  occur 
in  making  water.  When  the  ulcer  has  made  a  fur- 
ther progress,  and  a  communication  has  thereby  ta- 
ken place  between  the  bladder  and  the  uterus,  or  be- 
tween the  bladder  and  the  vagina,  or  between  the 
bladder  and  the  rectum,  it  may  be  distinguished 
by  the  urine  passing  either  through  the  vagina  or 
the  anus,  attended  with  pain  and  irritation. 


When  two  chambers  are  just  beginning  to  be  form- 
ed in  the  bladder,  very  little  inconvenience  is  prob- 
ably felt,  because  the  communication  between  them 
at  this  time  is  very  large.  Under  such  circumstan- 
ces it  seems  hardly  possible  to  detect  the  nature  of 
the  disease  in  the  living  body  ;  but  when  the  disease 
has  made  a  considerable  progress,  and  the  communi- 
cation between  the  two  chambers  has  become  very 
narrow,  it  may  be  ascertained,  or  at  least  conjectur- 
ed about  with  great  probability,  from  the  following 
circumstances.  There  will  then  be  a  considerable 
circumscribed  tumour  above  the  pubes  in  the  situa- 
tion of  the  bladder  when  distended,  much  less  urine 
will  be  made  than  the  natural  quantity,  and  the  tu- 
mour will  not  be  sensibly  lessened  by  it ;  or  if  a  ca- 
theter be  introduced,  little  urine  will  be  evacuated, 
and  the  tumour  above  the  pubes  will  still  remain  the 
same.     But  it  will  occasionally  happen,  by  some  par- 


[      191     ] 

ticular  attitude  of  the  body,  that  the  urine  will  pass 
from  the  upper  chamber  of  the  bladder  into  the  low- 
er, and  from  this  it  will  be  evacuated  by  the  urethra  ; 
under  such  circumstances  there  will  be  a  much  larger 
quantity  of  urine  made  than  usual,  the  tumour  above 
the  pubes  will  disappear,  and  the  patient  will  receive 
immediate  relief,  which  will  continue  till  there  is  an- 
other accumulation  of  urine. 


There  are  no  symptoms  which  particularly  distin- 
guish the  existence  of  fungous  excrescences  in  the 
bladder.  I  hey  produce  difficulty  in  making  water, 
which  will  be  greater  according  as  the  excrescence  is 
large,  or  as  it  is  situated  near  the  neck  of  the  bladder. 
When  the  excrescence  is  very  near  the  neck  of  the 
bladder,  the  disease  mav  be  ascertained  by  the  intro- 
duction of  the  sound  into  the  urethra.  The  extrem- 
ity of  the  sound  will  come  in  contact  with  the  excres- 
cence, and  will  give  the  sensation  of  its  pressing 
against  a  soft  tumour.  It  may  be  said,  that  this  case 
will  with  difficulty  be  distinguished  by  such  an  exam- 
ination, from  an  enlargement  of  the  prostate  gland. 
By  examining,  however,  into  the  state  of  the  pros- 
tate gland  in  the  usual  way  through  the  rectum,  the 
one  case  may  be  sufficiently  distinguished  from  the 
other. 


The  symptoms  which  belong  to' a  polypus  formed 
in  the  bladder,  arc  unknown  to  me  ;  but  they  are 
probably  much  the  same  with  those  which  attend  fun- 
gous excrescences  in  the  bladder,  as  above  described. 


The  symptoms  which  attend  calculi  in  the  blad- 
der are  well  known.  There  is  an  uneasy  sensation 
at  the  orifice  of  the  urethra  after  making  water,  or 
after  exercise.     When  the  calculus   is   large,  a  dull 


[     192     ] 

pain  is  generally  felt  at  the  neck  of  the  bladder.  The 
attempts  to  make  water  are  frequent,  and  it  often 
passes  drop  by  drop,  or  the  stream  is  suddenly  inter- 
rupted. The  urine  deposits  a  large  proportion  of  a 
mucous  sediment,  which  is  produced  by  the  mucous 
glands  at  the  neck  of  the  bladder  being  irritated  by 
the  calculus  to  an  increased  secretion.  The  urine  is 
also  occasionally  tinged  with  blood,  from  some  small 
blood  vessels  being  ruptured  by  a  rough  part  of  the 
stone,  and  this  is  most  apt  to  happen  after  some  jolt- 
ing motion.  There  is  tenesmus,  in  consequence  of 
the  connection  of  the  rectum  with  the  bladder,  and 
the  sympathy  which  has  been  established  between 
their  respective  functions. 

When  the  calculous  matter  is  soft  resembling  mor- 
tar, there  is  great  pain  and  difficulty  in  making  water, 
which  is  voided  frequently,  and  in  small  quantity  ; 
portions  of  this  matter  are  occasionally  discharged 
along  with  the  urine,  and  generally  mixed  with  a  ropy 
mucus  tinged  with  blood. 


[     193     ] 


CHAP.  XV. 


DISEASED    APPEARANCES   OF   THE  VESICUL^E  SEMI- 
.  NALES. 


JL  HE  diseased  appearances  of  the  vesicular  semi- 
nales  are  but  little  known,  because  from  their  situa- 
tion these  bodies  cannot  be  seen  without  a  good  deal 
of  dissection  ;  whereas  many  of  the  viscera  come  im- 
mediately into  view  when  the  cavity  in  which  they 
are  lodged  is  simply  laid  open  :  diseased  appearances, 
however,  have  been  occasionally  observed  in  the  vesi- 
cular seminales. 


Vcsiculae  Seminales  inflamed. 

It  has  never  occurred  to  me  to  observe  the  vesicu-. 
las  seminales  inflamed  by  themselves,  although  they 
are,  doubtless,  liable  to  this  disease,  like  other  parts 
of  the  body.  I  have  seen  them,  however,  involved 
in  the  natural  consequences  of  inflammation  with  the 
surrounding  parts.  Thus  I  have  seen  the  posterior 
surface  of  the  bladder,  the  vesiculae  seminales,  and 
a  portion  of  the  rectum  adhering  with  unusual  firm- 
ness together,  in  the  same  manner  as  other  parts  of 
the  body  do  after  inflammation.  Some  few  instances, 
however,  have  occurred,  in  which  so  great  an  inflam* 
mation  had  been  excited  in  the  vesicular  seminales, 
as  to  terminate  in  suppuration.* 

•  Sec  Sccmmcvring's  Germ.  Trans,  p,  1S4 

A  a 


•  C     194     J 

Vesiculce  Seminales  scrofulous. 

The  vesiculae  seminales  are  also  affected  with  scrof- 
ula. I  recollect  to  have  seen  one  of  the  vesiculae 
seminales  filled  with  true  scrofulous  matter,  the  dis- 
tinguishing characteristic  of  which  has  been  often 
mentioned. 


Ducts  of  the  Vesiculx  Seminales  terminating  in  a  Cul- 

de-sae. 

The  ducts  of  the  vesiculas  seminales  open  natural- 
ly by  two  distinct  orifices  into  the  cavity  of  the  pros- 
tate gland,  but  they  are  occasionally  wanting,  and  the 
vesiculae  seminales  terminate  in  a  cul-de-sac.  The 
vasa  defcrentia  are  at  the  same  time  without  their  nat- 
ural termination,  for  they  end  in  the  cul-de-sac  o£ 
the  vesiculae  seminales.  This  is  a  species  of  mon- 
strosity which  is  very  rare,  but  it  is  of  great  conse- 
quence, because  it  prevents  the  semen  from  passing 
into  the  urethra,  and  frustrates  one  of  the  most  im- 
portant functions  in  the  animal  economy-  An  in- 
stance of  this  sort  of  malformation  is  preserved  in 
Dr.  Hunter's  collection. 


Vesiculce  Seminales  very  small. 

The  vesiculae  seminales  differ  a  good  deal  in  their 
size  in  different  adult  bodies,  and  indeed  it  is  very 
fcommon  for  the  one  to  be  considerably  smaller  than 
the  other  ;  but  I  have  oftener  than  once  seen  both  of 
them  so  small  that  they  must  have  been  very  little 
able  to  fulfil  the  intentions  for  which  they  were 
formed. 

One  of  the  Vesiculce  Seminales  wanting. 

One  of  the  vesiculae  seminales  is  occasionally  want- 
ing altogether.     Under  such  circumstances  I  believe 


t     195     ] 

tli at  the  extremity  of  the  vas  deferens  upon  that  side 
is  generally  enlarged  and  tortuous,  becoming  a  sort 
■of  substitute  for  it.  This  was  at  least  the  case  in  the 
instance  which  I  have  seen  of  this  mode  of  formation- 
The  extremity  of  the  vas  deferens  has  at  all  times  a 
structure  similar  to  that  of  the  vesicular  seminales, 
.and  renders  therefore  this  conjecture  very  probable. 

Vesicula  Seminales  scirrhous. 

The  vesicular  seminales  have  also  been  observed 
to  be  scirrhous;  but  this  is  very  uncommon.* 


Small  stones  have  also  been  seen  in  the  vesicular 
seminales,  but  they  have  not  fallen  under  my  own 
•bservation,  and  they  are  of  very  rare  occurrence. f 


SYMPTOMS. 

The  symptoms  which  attend  diseases  of  the  vesi- 
■culse  seminales,  have  not  been  attempted  to  be  dis- 
criminated by  authors,  and  must,  from  circumstan- 
ces, be  very  difficult  to  ascertain.  It  has  onlv  occur- 
red  to  myself  to  observe  some  diseased  changes  of 
them  in  the  dead  body  ;  and  I  have  had  no  opportu- 
nity of  tracing  the  symptoms  which  accompany  these 
changes  during  life. 

•  See  Morgagni  Epist.  XLVI-  Art.  5. 
|  Sec  Soemmerring's  Germ.  Trans*  p.  195- 


[     156     ] 


CHAP.  XVI. 


DISEASED      APPEARANCES      OF     THE      PROSTATE 
GLAND. 


Abscess  in  the  Prostate  Gland. 


T 


HE  prostate  gland  is  not  often  found  in  a  state 
of  common  inflammation.  I  have  seen,  however,  an 
abscess  in  it,  without  any  uncommon  thickening  and 
enlargement  of  the  gland,  and  where  the  pus  appear- 
ed to  be  of  the  common  sort.  This  must  be  consid- 
ered as  being  a  common  abscess,  and  must  have  been 
preceded  by  the  ordinary  sort  of  inflammation. 

Scrofula  of  the  Prostate  Gland. 

The  prostate  gland  is  sometimes  scrofulous.  I 
have  seen,  in  cutting  into  it,  precisely  the  same  white 
curdly  matter,  which  is  formed  in  a  scrofulous  absor- 
bent gland.  In  squeezing  it  also,  I  have  forced  out 
from  its  ducts  a  scrofulous  pus. 

Scirrhus  of  the  Prostate  Gland. 

The  most  common  disease  of  the  prostate  gland  is 
a  scirrhous  enlargement  of  it.  The  prostate  gland, 
it  is  well  known,  is  naturally  about  the  size  of  a  large 
chesnut,  but  when  it  is  attacked  by  scirrhus,  it  is  of- 
ten enlarged  to  the  size  of  the  fist.     In  this  enlarged 

'c,  when  cut  into  it  exhibits  a  very  firm,  whitish, 


[     197     ] 

or  brown  substance,  with  membranous  septa  running 
through  it  in  various  directions,  which  arc  often  very 
strongly  marked.  This  is  the  common  appearance 
of  scirrhus  in  other  parts  of  the  body.  When  the 
prostate  gland  is  a  good  deal  enlarged,  its  cavity  be- 
comes deeper  from  the  growth  of  its  sides,  and  the 
posterior  extremity  forms  a  considerable  projection 
into  the  cavity  of  the  bladder,  which  interrupts  the 
passage  of  the  urine  into  the  urethra.*  According  to 
the  degree  of  this  projection,  the  urine  is  passed  with 
greater  or  less  difficulty,  as  well  as  an  instrument  for 
drawing  it  off.  When  the  projection  is  very  great,  it 
has  sometimes  been  found  impossible  to  pass  an  in- 
strument over  the  projection,  and  an  artificial  pas- 
sage has  been  made  through  it  accidentally,  by  which 
the  urine  has  been  evacuated.  Under  such  circum- 
stances the  gland  has  been  known  net  to  be  irritated 
by  the  violence  used  in  making  this  new  passage,  and 
life  has  been  prolonged  for  a  greater  length  of  time 
than  it  would  have  been  otherwise.  Still,  however, 
the  instrument  ought  to  be  made  to  pass  over  the 
projection,  if  possible,  and  we  should  never  run  the 
risk,  by  injuring  the  gland,  of  bringing  on  immedi- 
ately fatal  consequences. 

Sometimes  in  the  progress  of  the  enlargement  the 
prostate  gland  grows  irregularly,  and  a  winding  pas- 
sage is  formed  through  it,  by  an  alteration  in  the 
shape  of  its  cavity  This  increases  the  difficulty  to 
the  patient  of  making  water,  and  to  the  surgeon  of 
introducing  an  instrument.  When  the  prostate 
gland  is  enlarged,  its  internal  surface  is  sometimes 
ulcerated,  but  commonly  it  is  not. |     Fistulous  com- 

*  Mr.  Home  has  lately  discovered  thajj  this  posterior  projection  is  wing 
to  the  enlargement  of  a  small  oepai  ate  lobule  of  the  prostate  gland,  not  hith- 
erto known. 

f  There  rccms  to  be  little  disposition  to  the  formation  of  an  nicer  in  this 

mj'c  of  the  prostate  gland.     This  disease  may    thereforebe  considered  not 

improperly  a^  in  some  degree  different  from  diseases  in   other  parts  of  the 

body,  which  aie  afended  with  a  similar  structure,  but  which  are  prone  to  run 
into  ulceration. 


I     198     ] 


"munications  are  sometimes  formed  between  an  enlar*. 
ged  prostate  gland  and  the  rectum. 

It  is  obvious  too.  from  what  has  been  mentioned, 
that  in  an  enlarged  state  of  the  prostate  gland,  the  dif- 
ficulty of  making  water  must  be  very  great.  This 
difficulty  excites  extraordinary  and  very  frequent  ef- 
forts in  the  bladder  to  overcome  it.  Its  muscular  coat 
becomes  consequently  much  stronger  and  thicker, 
than  in  the  natural  state.  A  prostate  gland,  there- 
fore is  never  found  enlarged  to  any  considerable  de- 
gree, without  the  bladder  ha  ing  undergone  this 
change  in  its  muscular  coat.  This  disease  is  hardly 
ever  to  be  found  in  a  young  person,  but  is  not  at  all 
uncommon  at  an  advanced  period  of  life. 

Calculi  in  the  Ducts  of  the  Prostate  Gland. 

There  is  another  disease  of  the  prostate  gland, 
which  occasionally  takes  place,  although  it  is  by  no 
means  so  frequent  as  the  former,  viz.  a  formation  of 
«mall  calculi,  which  are  lodged  in  its  ducts.  They 
are  usually  of  the  size  of  a  small  pea,  and  those  which 
I  have  seen  have  been  of  a  lighter  or  a  darker  brown 
colour.  They  have  been  found  by  Dr.  Wm.  Hyde 
Wollaston  to  consist  of  phosphorated  lime  in  the  state 
of  neutralization. 


Ducts  of  the  Prostate  Gland  enlarged. 

The  prostate  gland  is  sometimes  seen  with  its  cavi- 
ty very  much  widened,  and  its  ducts  enlarged*.  In 
the  natural  state  of  the  gland,  the  orifices  of  its  ducts 
can  hardly  be  seen,  but  they  sometimes  are  so  much 
enlarged  as  to  be  capable  of  admitting  a  crow  quill. 
When  the  ducts  are  so  enlarged,  there  is  always  a 
great  obstruction  to  the  passage  of  the  urine  through 
the  urethra,  arising  most  commonly  from  stricture 
there.  The  urine,  either  passing  in  very  small  quan- 
tity, or  being  entirely  prevented  from  passing,  is  ac- 


[     199     J 

cumulated  in  the  cavity  of  the  prostate  gland  and  the 
bladder.  The  effect  of  this  accumulation  is,  that  the 
cavity  of  the  prostate  gland  is  widened,  and  the  ducts 
very  much  enlarged.  The  bladder  too,  from  making 
extraordinary  efforts  to  overcome  the  obstruction, 
has  its  muscular  coat  gradually  thickened,  and  often 
to  a  very  considerable  degree.  Attending,  therefore, 
this  state  of  the  prostate  gland,  there  is  a  thickened 
bladder,  and  an  obstructed  urethra. 

The  Prostate  Gland  preternatural! y  small. 

I  have  also  seen  the  prostate  gland  of  an  extremely 
small  size,  so  that  it  could  hardly  be  considered  as  be- 
ing fit  for  its  office.  It  was  attended  with  a  mon- 
strous formation  of  the  urinary  bladder  and  some  of 
the  organs  of  generation,  and  has  been  particularly 
described  by  me  in  the  Medical  and  ChirurgicaL 
Transactions.* 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  of  the 
prostate  gland  have  been  little  taken  notice  of  by  au- 
thors. It  is  reasonable  to  think,  that  there  will  be  a 
sense  of  pain  more  or  less  accute  at  the  neck  of  the 
bladder,  with  much  difficulty  in  making  water,  and 
probably  tenesmus.  This  disease  may  be  distinguish- 
ed from  a  scirrhous  enlargement  of  the  prostate  gland, 
by  its  quick  progress,  and  by  the  pain  which  is  felt 
in  it. 


When  the  prostate  gland  is  affected  with  scrofula, 
little  inconvenience  is  probably  felt  in  an  early  state 
of  the  complaint  ;  but  if  the  gland  should  increase 
very  considerably  in   its  size,  those  symptoms  must 

•  See  paje  194. 


[     200     ] 

necessarily  arise,  which  depend  upon  its  enlargement, 
and  which  are  just  about  to  be  mentioned. 


When  the  prostate  gland  becomes  enlarged  from 
scirrhus,  there  is  a  difficulty  in  voiding  the  urine,  and 
a  small  quantity  only  is  discharged  at  a  time,  so  that 
the  bladder  is  kept  always  nearly  full.  There  is  some- 
times a  total  inability  to  evacuate  the  urine.  The 
faeces  are  also  passed  with  difficulty,  and  when  the 
operation  is  over,  there  is  still  a  feeling  of  something 
more  to  be  discharged.  The  straining  which  attends 
the  evacuation  of  the  urine  and  the  faeces  not  '.infre- 
quently forces  out  some  mucus,  which  had  been  se- 
creted by  this  gland.  A  bougie  or  catheter  is  either 
passed  into  the  bladder  with  difficulty,  or  on  some 
occasions  is  not  capable  of  being  passed  at  all. 


Calculi  occur  so  rarely  in  the  prostate  gland,  that 
their  symptoms  have  been  little  taken  notice  of  by  au- 
thors. When  the  calculi  are  very  small,  so  as  to  be 
confined  entirely  within  the  ducts  of  the  prostate 
gland,  it  is  probable  that  little -^inconvenience  is  pro- 
duced by  them.  When  they  are  large,  and  form  a 
projection  into  the  cavity  of  the  prostate  gland;  there 
must  necessarily  be  difficulty  in  voiding  the  urine, 
and  there  will  be  the  same  feeling  when  a  sound  or 
catheter  is  attempted  to  be  passed  into  the  bladder,  as 
if  an  urinary  calculus  had  got  fixed  or  impacted  in  the 
neck  of  the  bladder. 


C     201      ] 


CHAP.  XVII. 


DISEASED     Al'FKARANCES   OF    THE   URETHRA, 


Abscesses. 


A 


BSCESSES  are  occasionally  formed  in  the 
membranous  part  of  the  urethra.  These  may  arise 
from  an  inflammation,  produced  by  some  latent  cause, 
as  abscesses  are  formed  in  any  other  part  of  the 
body  ;  but  they  happen  most  frequently  from  an  ob- 
struction to  the  passage  of  the  urine  through  the 
urethra.  This  obstruction  is  produced  generally  by 
a  stricture  in  some  part  of  this  canal,  and  most  fre- 
quently it  is  at  or  near  the  bulb  of  the  corpus  spongi- 
osum urethra?.  The  urine  being  forced  by  the  efforts 
of  the  bladder  behind  the  stricture,  irritates  that  part, 
producing  inflammation  and  suppuration  ;  the  abscess 
breaks  externally,  and  the  urine  is  evacuated  by  this 
opening.  While  it  remains  in  the  state  of  an  ab- 
scess, it  is  not  at  all  different  from  any  common  ab- 
scess which  may  communicate  with  the  bladder. 

Fistulce. 

While  the  obstruction  in  the  urethra  continues,  the 
opening  made   by  the  breaking   of  the  abscess  is  not 
disposed  to  heal  up,  but  a  fistulous   orifice  is  gradu- 
ally formed.     This  is  surrounded  with  parts  some- 
B  b 


[     202     ]      * 

wftat  thickened  and  hard,  as  fistula;  are  generally. 
The  most  common  situation  for  these  fistulous  open- 
ings is  behind  the  scrotum,  because  the  most  com- 
mon situation  of  the  stricture  is  at  or  near  the  bulb  of 
the  corpus  spongiosum  urethra?.  Not  uncommonly 
there  are  rnore  than  one  of  these  openings  leading  to 
short  canals  which  run  in  different  directions. 

Stone  in  the  Cavity  of  the  membranous  part  of  the- 

Urethra. 

The  cavity  of  the  membranous  part  of  the  urethra 
I  have  seen  distended  into  a  bag  large  enough  to  con- 
tain a  hen's  egg.  This  bag  was  occasioned  by  a 
large  stone  which  had  lodged  there.  The  stone  had 
probably  been  driven  into  the  cavity  of  the  membran- 
ous part  of  the  urethra,  by  the  stream  of  urine  from 
the  bladder,  but  was  too  large  to  pass  by  the  same 
means  through  the  whole  length  of  the  urethra  ;  it 
therefore  stuck  in  that  situation,  and  was  gradually 
increased  to  the  size  which  we  have  described,  by 
the  contact  of  the  urine,  similar  to  the  growth  of  a 
stone  In  the  pelvis  of  the  ureters. 


Cowper's  Glands  seldom  observed  to  be  diseased. 

I  do  not  recollect  to  have  seen  Cowper's  glands  dis- 
eased, which  are  situated  near  this  part  of  the  ureth- 
ra. They  are  doubtless  liable  to  changes  from  dis- 
ease, like  other  parts  of  the  body  ;  but  they  are  small 
and  difficult  of  access,  so  that  they  have  very  seldom 
become  an  object  of  examination. 

Morgagni  mentions  one  of  them  being  converted 
into  a  ligamentous  substance  ;*  and  the  excretory 
duct  of  one  in  another  instance  being  obliterated,  t 

*  See  Morgagni,  Epist.  XLIV.  Art.  3. 
i  S<e  Morgagni,  EpJst.  ZLIV.  Art.  12. 


[     203     ] 

Inner  Membrane  cfthe  Urethra  inflamed. 

The  inner  membrane  of  the  urethra  is  very  liable 
to  be  inflamed,  particularly  at  its  anterior  extremity, 
and  the  inflammation  occasionally  spreads  over  the 
whole  extent  of  the  canal.  This  exhibits  no  appear- 
ance different  from  the  inflammation  of  membranes 
lining  secretory  canals  which  open  externally.  The 
membrane  is  much  more  crowded  with  small  blood 
vessels  than  in  a  natural  state,  and  there  is  an  in- 
creased secretion  of  the  glands  which  open  upon  it. 
The  inflammation  is  often  not  confined  to  the  inner 
membrane  of  the  urethra,  but  spreads  into  the  sub- 
stance of  the  corpus  spongiosum,  affecting  both  its 
cellular  structure  and  its  glands.  Under  these  cir- 
cumstances, the  corpus  spongiosum  is  enlarged  and 
harder  from  the  extravasation  of  the.coagulable  lymph 
into  its  cells,  and  is  more  vascular  than  in  a  natural 
state.  The  glands,  being  increased  in  size  from  the 
inflammation,  become  sensible  to  the  touch,  like  very 
small  rounded  tubercles. 

Ulcers  in  the  Urethra. 

Ulcers  are  also   seen   occasionally  in  laying  open 

"the  urethra,  but  these  are  not  frequent.     This  canal 

when  inflamed  .has  little  disposition   to  ulcerate,  as 

happens  also  to  some  other  canals  in  the  bedy,  as  for 

example  the  trachea. 

Stricture* 

i 

The  most  ordinary  diseased  appearance  of  the 
urethra  is  stricture.  This  consists  in  a  part  of  the 
canal  being  narrowed,  or  perhaps  altogether  oblitera- 
ted. It  may  take  place  in  any  part  of  the  canal,  but 
it  is  most  frequent  at  or  near  the  bulb  of  the  corpus 
spongiosum  urethra?.     This  stricture  sometimes  cor, 


[     204.     ] 

sists  simply  of  an  approximation  of  the  opposite  sides 
of  the  canal,  so  as  to  form  a  line  of  obstruction  ;  at 
other  times,  the  canal  is  narrowed  for  some  length. 
The  inner  membrane  at  the  stricture,  sometimes  ex- 
hibits the  natural  appearance  ;  sometimes  it  is  a  lit- 
tle thickened,  and  occasionally  its  surface  is  abraded 
or  ulcerated.  These  two  last  effects  are  generally 
produced  by  bougies  ;  and  sometimes  false  passages 
have  been  made  into  the  corpus  spongiosum  urethras 
in  consequence  of  employing  too  much  violence  in 
the  use  of  this  instrument.  There  is  often  more  than 
one  stricture  in  the  same  urethra.  It  sometimes  hap- 
pens too  that  the  stricture  is  more  on  one  side  of  the 
canal  than  the  other,  so  that  the  passage  there  is 
crooked. 

Caruncle. 

A  small  flesh)7  excrescence  sometimes  grows  in 
the  urethra.  This  is  called  a  caruncle,  and  used  for- 
merly to  be  considered  as  the  most  common  cause  of 
obstruction  in  this  canal  ;  but  since  dissections  of 
dead  bodies  have  become  more  frequent,  it  has  been 
found  in  reality  to  be  very  rare. 


A  layer  of  earthy  matter  in  the  urethra. 

I  have  known  one  instance  of  a  thin  layer  of  earthy 
matter  extending  from  the  bladder  through  the  whole 
length  of  the  urethra. 


Preternatural  Orifice  cf  the  Urethra. 

The  urethra  sometimes  does  not  open  at  the  pro- 
jecting extremity  of  the  glans  penis,  but  under  it, 
where  the  fraenum  is  naturally  situated  ;  and  in  such 
cases  there  is  no  fraenum.  It  consists  of  a  small 
rounded  opening,  much  less  than  the  natural  termin- 
ation in  the  glans.     I  have  known  an  instance  in  this 


[     205     ] 

structure  of  parts,  of  a  canal  being  formed  besides  the 
urethra,  about  two  inches  in  length,  which  termina- 
ted at  one  extremity  in  a  cul-de-sac,  and  at  the  other 
opened  on  the  glans,  where  the  urethra  commonly 
does.  How  far  this  variety  may  be  frequent  1  can- 
not pretend  to  determine.  This  deviation  in  the 
structure  is  not  to  be  considered  as  a  disease,  lint 
simply  as  a  malformation  of  parts,  and  is  not  attend- 
ed with  any  material  inconvenience  as  far  as  I  know. 
There  are  some  other  diseased  appearances  of  the 
penis,  such  as  ulcers,  pliymoses,  paraphymoses,  See. 
These  arc  external,  are  very  well  known,  and  do  not 
properly  fall  within  my  plan  ;  I  shall  therefore  omit 
them  entirely. 

SYMPTOMS. 

The  symptoms,  which  attend  the  inflammation  of 

the  inner  membrane  of  the  urethra,  are  too  well  known 
to  require  being  mentioned. 


In  stricture  of  the  urethra  there  is  difficulty  in  ma- 
king water,  which  is  greater  or  less  according  to  the 
degree  of  the  stricture  ;  the  stream  of  urine  is  small, 
sometimes  forked,  sometimes  scattered,  and  some- 
times the  urine  passes  away  in  drops  only.  There  is 
frequently  also  an  increased  secretion  of  mucus  from 
the  urethra,  resembling  a  gleet.  Vat  ions  other  symp- 
toms may  take  place,  in  consequence  of  the  parts  in 
the  neighbourhood  of  the  stricture  being  affected  ; 
and  even  the  constitution  is  sometimes  much  disturb- 
ed by  this  local  irritation,  exhibiting  very  different 
symptoms  in  different  individuals. 


When  the  urethra  is  obstructed  by  the  growth  of 
a  caruncle,  no  symptoms  .::■  known  by  which  it  may 
be  distinguished  from  a  ease  of  common  stricture. 


[     206     j 


CHAP.  XVIII. 


DISEASED   APPFARANCFS  OF  THE  TZSTICIE^    AV» 
THE     SPhRMATIC    CHORD. 


Hydrocele. 


YDROCELE,  or  a  collection  of  water  in  the 
tunica  vaginalis  testis,  is  a  very  common  disease  and 
is  confined  to  no  particular  period  of  life.  It  is 
not  unfrequent  in 'very  young  children,  and  in  them 
most  commonly  disappears  without  any  chirurgical 
treatment.  The  bag  in  which  the  water  is  accumu- 
lated is  of  apyramidical  shape,  and  approaches  more 
or  less  towards  the  ring  of  the  abdominal  muscle, 
according  to  the  degree  of  the  accumulation.  It 
sometimes  extends  almost  to  the  ring  itself.  The 
bag  is  also  more  or  less  thick  in  different  cases  :  it  is 
often  scarcely  thicker  than  the  tunica  \aginalis  in  its' 
natural  state  ;  sometimes,  when  the  accumulation  is 
large,  it  is  three  or  four  times  thicker,  and  is  obvi- 
ously laminated.  In  such  cases  too  the  testicle  is  a 
good  deal  compressed,  and  has  sometimes  been 
known  to  waste  in  consequence  of  this  compression. 
The  fluid  which  is  accumulated  is  of  a  yellowish,  a 
greenish,  or  brown  colour,  and  resembles  in  its 
properties  the  serum  of  the  blood.  This  disease,  in 
persons  who  are  advanced  in  life,  is  frequently  com- 
bined with  a  scirrhous  state  of  the  testicle,  which  will 
be  afterwards  particularly  described. 

In  almost  all  cases  of  hydrocele  the  water  is  con- 
tained  in  one  bag,  but  in  a  few  instances  it  has  been 
known  to  be  contained  in  several  cysts.     Of  this  I 


['    207     J 

recollect  a  remarkable  example  which  occurred  a  few 
years  ago.  This  variety  is  probably  produced  by 
repeated  partial  inflammations  on  the  inner  surface  of 
the  tunica  vaginalis,  and  occasioning  adhesions,  which 
put  on  the  appearance  of  cysts. 

Hydatids. 

Hydatids  have  sometimes  been  found  in  the  cavi- 
ty of  the  tunica  vaginalis  testis,  either  loose  or  ad- 
hering ;  they  are,  I  believe,  not  very  uncommon, 
but  I  have  had  no  favourable  opportunity  of  examin- 
ing them  accurately. 

Loose  Cartilages  in  the  Tunica  Taginaiis  Testis. 

Small  cartilages  are  sometimes  found  loose  in  the 
cavity  of  the  tunica  vaginalis  testis,  as  in  some  of  the 
joints  in  the  body,  more  especially  the  knee  joint. 
They  do  not  however  occur  in  the  former  so  fre- 
quently as  in  the  latter.  They  must  once  have  been 
attached  to  some  part  of  the  inner  surface  of  the  tu- 
nica vaginalis  testis,  by  very  small  processes  or  pe- 
duncles, and  by  the  motion  of  this  tunic  upon  the 
testicle  they  must  have  been  separated.  They  after- 
wards continue  to  lie  loose  in  the  cavity  of  the  tuni- 
ca vaginalis  testis,  and  are,  I  believe,  attended  with 
no  inconvenience.  An  example  of  this  kind  has  been 
seen  by  myself,  and  it'has  not  unfrequently  been  ob- 
served by  others. 

Adhesions. 

The  tunica  vaginalis  is  frequently  found  adhering- 
to  the  surface  of  the  testicle.  The  adhesion  is  some- 
times extended  over  the  whole  surface,  but  frequent- 
ly consists  only  of  scattered  processes  of  membrane. 
The  adhesions  are  sometimes  fine,  bu$  sometimes 
they  have  considerable  thickness,  and  connect  the 
tunica  vaginalis  to  the  body  of  the  testicle  more  or 


[     208     ] 

less  closely  in  different  cases.  They  are  produced  by 
some  previous  inflammation  in  the  tunica  vaginalis 
testis,  as  adhesions  are  formed  after  inflammation  in 
the  cavity  of  the  chest,  or  the  belly. 

Testicle  inflamed. 

The  substance  of  the  testicle  itself  is  very  fre- 
quently inflamed,  but  this  disease  is  commonly  re- 
moved by  art,  and  hardly  ever  becomes  an  object  of 
examination  after  death.  It  exhibits,  however,  pre- 
cisely the  same  appearances  as  the  inflammation  of 
the  substance  of  other  parts,  and  therefore  does  not 
require  to  be  particularly  described.  When  the  tes- 
ticle is  inflamed,  the  vas  deferens  sometimes  partakes 
cf  the  inflammation,  its  coats  becoming  considerably 
thickened,  and  in  some  instances  the  veins  of  the 
spermatic  chord  becoming  varicose.*  After  the  in- 
flammation of  the  testicle  has  subsided,  it  is  not  un- 
usual for  a  hardness  and  fulness  of  the  epidydimis  to 
remain  for  a  considerable  length  of  time,  or  even 
through  life.  This  depends  on  the  matter  which  had 
been  extravasated  during  the  inflammation  not  being 
afterwards  entirely  absorbed. 


Abscesses  of  the  Testicle. 

Abscesses  too  are  occasionally  formed  in  the  testi- 
cles, from  the  progress  of  .common  inflammation, 
and  are  attended  with  the  same  circumstances  as  ab- 
scesses in  other  parts. 

Testicle  scrofulous. 

The  testicle  is  sometimes  completely  changed 
from  its  natural  structure,  and  converted  into  a  truly 
scrofulous  mass.  Upon  such  occasions  it  is  gener- 
ally enlarged,  and  when  cut  into   shews  a  white,  or 

*  See  Mr.  Hunter  on  the  Venereal  Disease,  p.  54t 


[     209     ] 

yellowish-white,  curdly  substance,    which  is    some- 
times more   or  less  mixed  with  pus. 

Testicle  enlarged  and  pulp y. 

The  testicle  is  sometimes  much  enlarged,  and  con- 
verted into  an  uniform,  pulpy  matter,  in  which  its 
natural  structure  is  entirely  lost.  This  sort  of  change 
has  been  sometimes mistak en  for  scirrhus,  but  it  is 
very  different  from  what  is  called  scirrhus  in  other 
parts  of  the  body,  and  what  is  also  found  in  the  testi- 
cle itself. 


Scirrhus  and  Cancer  of  the  Testicle. 

1  he  testicle  is  also  found  much  enlarged,  and  chan- 
ged into  a  hard  mass,  which  is  generally  more  or  less 
intersected  by  membrane.  In  this  there  is  no  vestige 
of  the  natural  structure,  but  cells  arc  frequently  ob- 
servable in  it  containing  a  sanious  fluid  and  some- 
times there  is  a  mixture  of  cartilage.  This  state  of 
the  testicle  I  consider  as  the  true  scirrhus,  and,  ac- 
cording to  the  progress  of  the  disease,  the  epidydi- 
mis  and  the  spermatie  chord  arc  more  or  less,  or  not 
at  all,  affected.  This  disease  not  unfrequently  ad- 
vances to  form  a  foul  deep  ulcer  with  thickened 
edges,  or  throws  out  a  fungus,  and  then  it  is  called 
the  true  caneer  of  the  testicle. 

Testicle  cartilaginous. 

The  testicle  I  have  seen  much  enlarged,  and  chan-*, 
gcd  into  a  mass  of  cartilage.  There  was  also,  in  the 
case  to  which  I  allude,  an  ulcer  near  the  centre  of  the 
cartilage,  and  in  some  places  an  imperfect  appearance 
of  cysts  or  cells.  The  cartilage  did  not  seem  differ- 
ent  in  any  essential  property  from  common  cartilage, 
but  was  a  little  softer.  This  I  consider  as  depending 
upon  the  same  general  diseased  process  with  the 
Cc 


[    216    ] 

scirrhus  just  described,  for  sometimes  both  struc- 
tures are  blended  together  in  the  same  testicle. 

Testicle  bony. 

The  testicle  is  sometimes  converted  into  bone. 
A  lew  instances  only  of  this  disease  have  fallen  under 
rnv  observation,  and  in  them  the  bony  process 
had  not  extended  over  the  whole  substance  of  the  tes- 
ticle, but  had  affected  it  partially. 

A  Cyst  adhering  to  a  Testicle  containing  a  Vena   Me- 

dinensfs. 

I  have  seen  a  testicle  with  a  small  firm  cyst  adher- 
ing to  it,  which  contained  a  worm  of  that  sort  called 
vena  medinensis.  This  is  a  worm  of  considerable 
length,  with  a  smooth  surface,  and  an  uniform  apn> 
ance  ;  at  the  posterior  extremity  it  terminates  in  a 
slender  hook-like  process,  and  at  the  anterior,  there 
is  a  rounded  opening  or  mouth.  This  testicle  had 
probably  belonged  to  a  man  who  had  visited  some  of 
those  climates  in  which  the  vena  medinensis  is  found, 
and  who  had  brought  it  over  with  him  to  this  coun- 
try. 


The  Epidydimis  ending  in  a  Cul-de-sac. 

The  testicles  have  sometimes  this  sort  of  mal-for- 
mation,  that  the  epidydimis  does  not  terminate  in  a 
vas  deferens,  but  in  a  cul-de-sac.  In  these  cases  it 
is  evident  that  the  semen  cannot  be  evacuated  by  the 
urethra,  and  that  the  person  must  therefore  be  inca- 
pable of  procreation.  In  Dr.  Hunter's  collection,  a 
preparation  of  this  sort  is  preserved  ;  and  Mr.  Hun- 
te>-  has  givea  a  representation  of  it  in  his  Animal 
Economy.* 

*  .See  page  47,  plate  V. 


L    211    ] 

Stricture  of  the  Vas  Deferens. 

I  have  also  seen  a  portion  of  the  canal  of  the  vas 
deferens  obliterated  by  stricture.  This  had  not  been 
an  original  fault,  but  was  the  effect  of  a  diseased  pro- 
cess,  similar  probably  to  that  which  produces  stric- 
ture in  the  urethra,  and  must  have  prevented  the  se- 
men of  one  of  the  testicles  from  reaching  the  cavity 
of  the  prostate  gland. 

Testicles  very  small,  and  wasted. 

The  testicles  are  sometimes  cxceedinHv  small  in 
their  size.  I  have  known  one  case,  in  a  person  of 
middle  age,  where  each  of  them  was  not  larger  than 
the  extremity  of  the  finger  of  an  adult.     This,  as  ap- 

ared  from  its  history,  arose  from  a  fault  in  the 
original  formation,  and  was  attended  with  a  total 
want  of  the  natural  propensities.  It  is  much  more 
common  for  a  testicle  to  waste  either  spontaneously, 
or  in  consequence  of  a  previous  inflammation  or  com- 
pression, so  as  gradually  to  disappear  entirely. 
When  this  takes  place  in  one  testicle  only,  the  natu- 
ral powers  are  preserved  ;  but  when  it  takes  place  in 
both,  they  must  be  altogether  lost. 

Sometimes  one  testicle,  and  sometimes  both,  re- 
main in  the  cavity  of  the  abdomen  through  life,  so 
that  a  person  appears  to  have  only  one  testicle,  or  to 
be  without  them  altogether.  The  testicle  or  testicles, 
I  believe,  arc  in  these  cases  of  a  small  size  ;  and  Mr. 
Hunter  suspects  that  they  are  by  no  means  so  perfect 
as  when  the}  descend  into  the  scrotum. f 

Diseased  .Appearances  of  the  Spermatic  Chord. 
Spermatic  Chord  Scirrhous. 

The  spermatic  chord  is  also  liable  to  diseased  alter- 

•  Se?  Hunter  on  the  Venereal  Difease,  p.  209. 

f  Sec  Mr.  Hunter's  Observi  tioi  ■  o  certain  parts  of  the  Animal  Economy 
p.  «8. 


C     212     ] 

ations  of  structure  :  one  of  the  most  common  is  that 
of  its  becoming  scirrhous.  This  I  believe  to  be  very 
rarely,  if  at  all,  an  original  disease  of  the  chord,  but 
always,  or  almost  always,  spreads  to  it  from  the  tes- 
ticle. In  the  early  state  of  a  scirrhous  testicle  the 
spermatic  chord  is  perfectly  sound  ;  but  when  the 
disease  has  existed  for  a  considerable  time,  and  docs 
not  remain  stationary,  the  chord  becomes  at  length 
affected.  Under  such  circumstances  it  is  changed 
into  a  hard  mass,  exhibiting  the  same  appearance  of 
structure  as  the  testicle  itself.  During  the  last  stage 
the  disease  advances  to  the  loins,  so  as  to  affect  the 
absorbent  glands  there. 


Veins  of  the  Spermatic  Chord  varicose, 

A  disease  of  the  spermatic  chord  which  is  not  un- 
common, is  an  enlargement  of  its  veins  The  veins 
of  the  spermatic  chord  are  numerous  and  suppcrt  a 
very  long  column  of  blood.  This  last  circumstance, 
added  to  some  impediments  which  occasionally  take 
place  to  the  return  of  the  blood,  renders  the  veins 
frequently  enlarged.  This  enlargement  varies  very 
much  in  different  cases,  arising  from  the  degree  and 
the  continuance  of  the  impediment.  When  the  en- 
largement of  the  veins  is  very  considerable,  they  also 
become  varicose,  and  the  spermatic  chord  is  changed 
into  a  bulky  mass,  soft  to  the  feeling,  and  capable  of 
being  readily  diminished  upon  pressure.  In  this  state 
of  the  spermatid  chord,  the  testicle  is  sometimes 
wasted. 


Water  accumulated  in  the   cellular  Membrane  of  the 
Spermatic  chord. 

Water  has  sometimes  been  known  to  be  accumu- 
rnulated  in  the  cells  of  the  cellular  membrane,  which 
envelopes  the  vessels  of  the  spermatic  chord.  The 
cellular  membrane  of  this  part  of  the  body  is  in  con- 


C     213      ] 

siderablc  quantity,  and  when  water  is  accumulated  in 
its  cells,  a  large  swelling  is  formed  in  the  situation  of 
the  spermatic  chord,  which  is  readily  diminished  up- 
on pressure.  When  pressure  is  used,  the  swelling 
is  diminished,  not  only  by  a  part  of  the  water  being 
forced  into  the  cells  of  the  chord  within  the  abdomin- 
al ring,  but  also  by  its  being  forced  into  the  cellular 
membrane  under  the  skin  of  the  lower  part  of  the 
belly.  Many  pints  have  been  known  to  be  accumu- 
lated in  these  cells  It  has  never  occurred  to  myself 
to  see  this  disease,  and  therefore  1  have  had  no  op- 
portunity of  examining  the  nature  of  the  fluid  ;  but  I 
presume  it  is  oi  the  same  sort  with  what  is  usually 
found  in  anasarca. 


A  Sack  containing  jvater  formed  in  the   Spermatic 

chord. 

A  sack  has  also  been  known  to  be  formed  in  the 
spermatic  chord,  consisting  of  a  firm,  white  n 
brane,  and  containing  a  fluid  which  most  probably 
is  of  a  serous  nature.  Both  of  these  cases  ha>  e  been 
particularly  described  by  Mr,  Pott,  in  his  treatise  up- 
on Hydrocele.  * 


SYMPTOMS. 

The  existence  of  hydrocele  in  the  living botty",  ma} 
be  determined  by  the  shape  of  the  tumour,  which  is 
in  some  degree  pyramidal,  by  the  resistance fw.lxicl) it 
gives  upon  pressure,  by  the  want  of  pain  in  it,  and 
by  the  health  being  not  affected  by  it  Where  th 
tunica  vaginalis  is  thin,  and  the  swelling  is  placed  be- 
tween the  eye  and  a  lighted  candle,  it  will  appear 
transparent.  Where  the  tunica  vaginalis,  however, 
is  thick,  the  transparency  will  be  lost,  and  the  tumour 

"   ForUiri'irst   case,  sec   I'ott  on  Hj  c'uocc'.c,  p.  39i     I  iul,   see 

i :  -'  ■,  p.  <ST« 


[     214     ] 

to  the  feeling  will  be  harder,  and  less  compressible. 
But  still  it  will  not  have  the  same  degree  of  hardness 
as  a  scirrhous  testicle,  and  will  want  some  other  char- 
acteristic marks  which  belong  to  the  latter  disease. 


The  formation  of  hydatids  in  the  tunica  vaginalis 
testis  is  attended  with  symptoms  which  correspond 
very  much  with  those  of  hydrocele  ;  and  this  ease 
can  only  be  distinctly  known  by  laving  open  the  sack. 


An  inflamed  testicle  may  be  distinguished  from  a 
scirrhous  one  in  the  living  body,  by  a  slight  attention 
to  the  appearances,  and  to  the  history  of  the  case. 
The  progress  of  the  disease,  in  an  inflamed  testicle, 
is  commonly  rapid,  and  the  skin  of  the  scrotum  im- 
mediately covering  it  has  usually  a  blush  of  inflam- 
mation ;  but  in  a  scirrhous  testicle,  the  progress  of 
the  disease  is  slow,  and  the  skin  of  the  scrotum  re- 
tains its  natural  colour,  unless  it  be  really  affected  bv 
the  disease,  The  surface  of  the  tumour  in  an  inflam- 
ed testicle  is  uniform  and  smooth,  but  in  a  scirrhous 
testicle  is  often  irregular. 


When  a  testicle  is  scrofulous  or  pulpy,  it  may  be 
distinguished  from  a  scirrhous  testicle  by  its  greater 
softness,  by  the  little  pain  which  is  felt  in  it,  and  by 
the  health  being  usually  pretty  good,  even  when  the 
disease  has  been  of  long  standing. 


A  scirrhous  testicle  may  be  ascertained  in  the  living 
body,  by  its  great  hardness,  and  by  the  pain  that  is 
often  felt  in  it,  which  darts  along  the  spermatic  chord 
to  the  loins.  Its  progress  is  commonly  slow,  the 
spermatic  chord  becomes    ultimately  diseased,  and 


C     215     3 

the  general  health  at  length  much  impaired.  Whcu 
it  throws  out  a  fungus,  or  forms  an  ill-conditioned 
ulcer,  these  become  additional  external  marks  of  the 
nature  of  the  disease. 


The  encysted  tumour  of  the  spermatic  chord,  con- 
taining  water,  resembles,  in  some  appearances,  hy- 
drocele. It  may,  however,  be  distinguished  from  it 
by  the  testicle  being  felt  separate  and  entire  under 
the  tumour,  which  in  hydrocele  is  never  the  case- 


[     21G     ] 


CHAP.  XIX. 


DISEASED    APPgARANCFS    IX    THE    FEMALE    OR- 
GANS. 


Inflammation  of  the  Uterus. 


w 


HEN  the  uterus  becomes  inflamed,  it  takes 
place  almost  always  under  the  same  circumstances, 
viz.  very  soon  after  parturition.  The  inflammation 
is  sometimes  confined  to  the  uterus  itself,  or  its  ap- 
pendages, but  the  peritonaeum  in  the  neighbourhood 
is  most  commonly  affected,  and  frequently  over  its 
whole  extent.  The  uterus,  when  inflamed,  exhibits 
the  same  appearances  as  the  inflammation  of  the  sub- 
stance of  other  parts,  and  these. are  principally  ob- 
servable in  its  body  or  fundus.  The  inflammation  is 
frequently  found  to  creep  along  the  appendages  of  the 
uterus,  especially  the  Fallopian  tubes  and  ovaria  It 
often  advances  to  suppuration,  and  the  pus  is  gen- 
erally found  in  the  large  veins  of  the  womb,*  When 
the  peritonaeum  is  also  affected  by  inflammation,  it 
exhibits  the  same  appearances  which  we  formerly 
described  particularly  when  treating  of  the  inflamma- 
tion of  this  membrane  ;  but  the  extravasated  fluid, 
and  the  coagulable  lymph,  are  not  uncommonly  in 
very  large  proportion  to  the  degree  of  the  inflamma- 
tion.f 

*  Dr.  Clarke's  Essavs, p.  G9nr.il  "0, 

t  Dr.  Clarke,  who  has  examined  ij  i   at   many  women  that  hav 
ter  parturition  with  inflammation  of  the  peritonaeum,  has   observed   this  par, 
tictilarly.     See  Dr.  Clarke's  Essays,  p.  136. 


C     217     ] 

Malignant  Ulcer  of  the  Uterus. 

It  is  not  unusual  for  an  ulcer  to  be  formed  in  the 
uterus,  of  a  very  malignant  nature.  This  is  most 
apt  to  happen  in  women  at  the  middle  period  of  life, 
or  a  more  advanced  age;  but  it  sometimes  happens 
in  women  who  may  stiil  be  said  to  be  young.  The 
ulcer  generally  begins  in  the  cervix  uteri,  and  the 
uterus  is  at  the  same  time  somewhat  harder  and  lar- 
ger than  in  the  natural  state.  It  does  not,  however, 
grow  to  any  considerable  size.  The  ulcer  spreads 
from  the  cervix  to  the  fundus  uteri,  and  it  is  not  un- 
usual to  see  the  greater  part  of  the  fundus  destroyed 
by  it,  the  rest  being  changed  into  a  tattered  ulcera- 
ted mass.  The  ulceration  is  not  always  confined  in 
its  boundaries  to  the  uterus,  but  sometimes  spreads 
into  the  neighbouring  parts,  as  the  vagina,  the  blad- 
der, and  the  rectum,  making  communications  be- 
tween them,  and  producing  dreadful  haveck.  This 
disease  of  the  uterus  is  generally  considered  as  can- 
cer, but  it  differs  in  some  of  its  appearances  from 
what  is  acknowledged  to  be*  the  true  cancer  in  other 
parts  of  the  body.* 

Scirrhous  Enlargement  of  the  Uterus. 

It  sometimes  happens,  although  not  very  oftrn, 
that  the  uterus  enlarges  in  its  size,  and  becomes 
much  harder  than  in  its  natural  state.  This  change 
corresponds  very  much  to  that  of  scirrhus  in  other 
parts  of  the  body,  and  commonly  extends  over  the 
whole  of  the  uterus.  It  is  difficult  to  say  to  what 
size  the  uterus  may  at  length  arrive,  in  the  progress 
of  this  disease,  but  I  have   seen  it,  in  one  case,  as 

•  Thisdiseaced  change  I    formerly  confounded  with  the  scirrhous  enlarge- 
ment of  the  uterus,    considering  them  as    varieties  of  the   same  disease,  ami 
therefore  blending  their  description  tor.  ether  ;    but  in  consequence  of  tl.e.  accu- 
rate observations  of  Dr    Adams,  in  Ills  Esiayupcn  Morbii  Poisons,  1 
thought  it  proper  to  separate  them, 

Dd 


large  as  the  gravid  uterus  at  the  sixth  month.  If  a 
transverse  section  be  made  of  the  uterus  in  this  state, 
rt  is  found  to  consist  of  a  hard  substance,  intersected 
by  pretty  thick  membranes.  Ulceration  is  some- 
times discovered  upon  its  its  inner  surface,  but  I  be- 
lieve it  is  commonly  wanting.  Tubercles  are  occa- 
sionally formed  in  this  state  of  the  uterus,  being,  as 
it  were,  imbedded  in  its  substance,  and  they  have  a 
structure  very  much  resembling  that  of  the  uterus  it 
Self. 


Tubercles  of  the  Uterus* 

Hani  tubercles  often  grow  from  the  uterus,  which 
are  either  imbedded  in  its  substance,  or  arise  from 
its  outer  surface.  Thev  vary  a  u:ood  deal  in  their 
size,  viz.  from  that  of  a  hazel  nut  to  more  than  the 
size  of  the  fist.  They  are  irregular  in  their  shape> 
but  are  commonly  rounded,  and  are  often  in  some 
degree  knotted.  These,  when  cut  into,  exhibit  a 
hard  whitish  substance,  intersected  by  membranous 
septa,  which  are  commonly  very  thick  and  strong. 
They  seem  to  have  little  disposition  to  ulceration, 
for  they  are  very  rarely  found  affected  by  this  pro- 
cess. The  uterus  in  this  state  of  disease,  is  general- 
ly or"  the  natural  size,  and  possesses  the  healthy  struc- 
ture, but  occasionally  it  is  much  enlarged. 

A  mass  of  the  same  kind  is  sometimes  found  in  the 
cavity  of  the  uterus,  and  ofrcn  grows  to  a  very  large 
size.  I  have  seen  it  a  good  deal  larger  than  a  child's 
head  at  birth.  This  mass  when  cut  into,  exhibits, 
precisely  the  same  appearances  as  these  we  have  so 
lately  described.  It  is  remarkable,  that  such  masses 
wiihin  the  cavity  of  the  uterus  commonly  do  not  ad- 
here in  any  part  closely  to  it,  but  are  connected  with 
it  loosely,  by  the  intervention  of  cellular  membrane, 
and  small  blood  vessels,  so  that  they  can  be  very  ea- 
sily peeled  off,  without  injuring  the  structure  of  the 
uteius.     The  uterus  itself  is  more  or  less  enlarged 


[     219     ] 

according  to  the  bulk  of  the  mass  it  contains,  bXit    it 
appears  to  be  perfectly  healthy  in  its  structure. 


Polypus. 

Polypus  forms  a  very  common  disease  of  the  ute- 
rus, and  may  take  place  almost  at  any  period  of  life  ; 
it  is  more  frequent,  however,  at  the  middle  or  ad- 
vanced age,  and  rarely  happens  in  persons  who  are 
young.  By  a  polypus  is  meant  a  diseased  mass, 
which  adheres  to  some  part  of  the  cavity  of  the  ute- 
rus, by  a  sort  of  neck  or  narrower  portion.  It  is  of 
different  kinds  :  the  most  common  kind  is  hard,  and 
consists  of  a  substance,  divided  by  thick  membranous 
septa.  When  cut  into,  it  shews  precisely  the  same 
structure  as  the  tubercle  of  the  uterus  just  described  ; 
so  that  a  person  looking  upon  a  section  of  the  one 
and  the  other  out  of  the  body,  could  not  at  all  distin- 
guish between  them.  This  sort  of  polypus  varies 
very  much  in  its  size,  some  being  not  larger  than  a 
walnut,  and  others  be imr  larger  than  a  child's  head. 
It  adheres  by  a  narrower  portion  or  neck,  whieh  va- 
ries a  great  deal  in  its  size,  and  in  its  proportion  to  the 
body  of  the  polypus.  The  largest  polypus  I  ever  saw 
was  suspended  by  a  neck  hardly  thicker  than  the 
thumb  ;  and  I  have  seen  a  polypus,  less  than  the  fist, 
adhering  by  a  neck  fully  as  thick  as  the  wrist. 

The  place  of  adhesion  also  differs  considerably.  If 
is  most  commonly  at  the  fundus  uteri,  but  it  may 
take  place  in  any  other  part  ;  and  I  have  seen  a  small 
polypus  adhering  just  on  the  inner  part  of  the  lip  oi 
the  os  uteri.  When  a  polypus  is  cf  any  considerable 
size,  there  is  generally  one  only  ;  but  I  have  occa- 
sionally seen  on  the  inside  of  the  uterus,  two  or  three 
small  polypi,  and  in  some  instances,  several  polypi 
have  been  known  to  grow  from  the  uterus  in  succes- 
sion. 

Another  sort  of  polypus  takes  place  in  the  uterus, 
which    consists  of  an    irregular,    bloody   substar.ee, 


[     220     ] 

with  a  number  of  tattered  processes  hanging  from  it. 
This  when  cut  into  exhibits  two  different  appearan- 
ces of  structure  :  the  one  appearance  is  that  of  a  spon- 
gy  m  iss,  consisting  of  laminae,  with  small  interstitial 
cavities  between  them  ;  the  other  is  that  of  a  very 
loos'j  texture,  consisting  of  large  irregular  cavities. 
It  is  very  obvious  that,  in  proportion  as  a  polypus 
grows,  the  cavity  of  the  uterus  must  be  enlarged,  and 
the  same  change  must  take  place  in  the  vagina,  when 
a  poiypus  protrudes  from  the  uterus  into  this  canal. 

The  Inversion  of  the  Uterus. 

The  inversion  of  the  uterus  occasionally  takes 
place,  and  principally  from  two  causes,  viz.  from  the 
weight  of  a  polypus,  or  from  violent  pulling  in  at- 
tempts to  remove  the  placenta.  When  the  inversion 
is  incomplete,  the  fundus  uteri  forms  a  tumour  with- 
in its  cavity  ;  there  is  at  the  same  time  an  appearance 
of  fissure  upon  the  outside  of  the  uterus,  where  the. 
fundus  usually  is ;  and  the  Fallopian  tubes,  the  round 
ligaments,  and  the  ligaments  of  the  ovaria,  are  drawn 
inwards  at  both  edges  of  the  fissure.  The  uterus, 
particularly  after  labour,  is  sometimes  inverted  entire- 
ly, the  inner  surface  being  exposed,  and  the  fundus 
uteri  forming  a  large  tumour  within  the  vagina, 
and  in  some  cases  even  on  the  outside  of  the  labia. 


Prolapsus  Uteri. 

The  uterus  sometimes  leaves  its  natural  situation 
and  falls  downwards,  so  as  either  to  get  to  the  exter- 
nal parts,  or  out  of  the  body  entirely.  This  is  most 
apt  to  happen  when  women  have  a  large  pelvis,  and 
where  the  soft  parts  have  been  very  much  relaxed 
by  repeated  and  severe  labours.  This  disease  is  cal- 
led prolapsus  uteri,  and  will  be  explained  more  par- 
ticularly when  we  come  to  treat  of  the  diseases  of  the 


[     221     ] 

vagina.     It  is  much  more  frequent  than  the  other  dis- 
ease called  the  inversio  uteri. 


Stricture  in  the  cavity  of  the  Uterus. 

A  stricture  is  sometimes  formed  within  the  cavity 
of  the  uterus,  so  that  its  cavity  at  one  part  is  oblitera- 
ted entirely.  This  I  believe  almost  alwa\s  to  take 
place  at  one  part,  viz.  where  the  cavity  of  the  fundus 
uteri  terminates,  and  that  of  the  cervix  begins,  for 
in  this  place  the  cavity  of  the  uterus  is  narrowest. 
As  the  sides  of  the  cavity  round  this  place  lie  very 
near  each  other,  and  form  naturally  a  small  aperture, 
it  is  probable  that  some  slight  inflammation  may  unite 
the  parts  together,  and  shut  up  the  aperture  ;  or  the 
parts  may  gradually  approach  each  other  without  this 
cause,  as  in  strictures  of  the  urethra. 


The  Os  Uteri  contracted,  and  closed  up. 

The  os  uteri  has  been  found  to  be  so  contracted, 
as  to  have  its  passage  in  a  great  measure  obliterated  ;* 
and  it  has  even  been  known  to  be  closed  up,  by  the 
growth  of  an  adventitious  membrane. f 

Uterus  bony. 

The  substance  of  the  uterus  is  sometimes  more  or 
less  converted  into  bone.  This  arises  from  a  partic- 
ular morbid  action  of  its  blood  vessels,  by  which  they 
screte  from  the  blood  bony  matter,  and  it  is  a  very 
rare  disease. 


The  Uterus  changed  into  an  earthy  Substance. 
The  uterus  has  also  been  known  to  be  converted 

•  Vid    Mcrgagni,  Epis-    LXVIT.   Art.  11. 
M'id.  M  r0aLi,i,  tpist,  XLVi.  Air.  17. 


[     222     ] 

into  an  earthy  substance.*  It  is  probably  of  the  same 
kind  with  the  earth  of  bones  ;  and  this  disease  prob- 
ably differs  only  from  the  former,  in  there  being  a 
less  proportion  of  animal  gluten,  to  combine  the 
earthy  particles  together. 

A  bony  mass  in  the  Cavity  of  the  Uterus. 

In  the  cavity  of  the  uterus  a  bony  mass  is  some- 
times found.  When  this  is  the  case,  I  suspect  that 
the  hard  fleshy  tubercle  within  the  cavity  of  the  ute- 
rus, such  as  we  lately  described,  has  been  converted 
into  bone.  This  at  least  had  taken  place  in  the  only 
instance  which  I  have  known  of  it,  (for  a  great  part 
of  the  tubercle  still  remained  unchanged)  and  I 
think  it  very  probable,  that  such  a  change  most  fre- 
quently happens  where  these  bony  tumours  are  found-. 

Stones  in  the  Cavity  of  the  Uterus. 

Stonesf  have  sometimes  been  found  in  the  cavity 
of  the  uterus.  These  are  described  by  authors  as 
varying  in  their  appearance,  some  being  of  a  dark, 
and  others  of  a  light  colour.  About  their  nature 
they  are  silent,  and  I  can  say  nothing  of  it  from  my 
own  knowledge,  as  it  has  never  occurred  to  me  to 
see  an  instance  of  this  disease.  Such  concretions  are 
probably  formed  from  matter  thrown  out  by  the 
small  arteries  which  open  upon  the  internal  surface  of 
the  litems,  and  are  in  some  degree  analogous  to  the 
concretions  which  arc  formed  in  some  glands  of  the 
body. 

Dead  Feet  us  in  the  Uterus  converted  into  an   earthy 

Mass. 

It  has  also  been  known  to  happen,  that  a  dead  fce- 
■•tus  has  remained  for  a  lorn;  time  in  the  cavitv  of  the 

*  V'id.  Lieutaud,  Tom.  I.  p.  .12.1. 
t  Vid.  Lieutaud,  Jom.  1    \)    ao.\ 


t     223     ] 

uterus,  and  has  there  been  gradually  changed  into  an 
earthy  mass  preserving  the  shape  of  the  child.* 


irate?'  in  the  Cavity  of  the  Uterus. 

Wate'r  has  sometimes  been  known  to  be  accumula- 
ted in  the  cavity  of  the  uterus  in  very  large  quantity.  \ 
In  some  cases  fifty,  sixty,  or  even  a  hundred  pints 
have  been  said  to  be  accumulated.  This  water  is 
sometimes  bloody  in  its  appearance,  and  sometimes 
of  a  yellowish  colour.     Of  its  nature  I  cannot   speak 

Sarticularlv,  as  1  have  never  seen  an  instance  of  this 
isease.  I  think  it  probable,  however,  that  the  wa- 
ter accumulated  in  the  cavity  of  the  uterus,  resem- 
bles in  its  properties  the  serum  ;  and  that  it  is  poured 
out  by  the  small  curling  arteries  of  the  uterus.  In 
cases  where  water  is  really  accumulated  in  the  cavity 
of  the  uterus,  one  must  suppose  a  stricture  of  the 
cervix,  otherwise  the  water  would  escape  gradually 
into  the  vagina  as  it  is  formed.  I  am  disposed  to  be- 
lieve, however,  that  where  water  has  been  said  to  be 
accumulated  in  the  cavity  of  the  uterus,  it  has  fre- 
quently been  really  in  one  or  more  large  hydatids  form- 
ed in  that  cavity. J 


Hydatids  in  the  Uterus. 

Large  masses  of  hydatids  §  have  also  been  found 
In  the  cavity  of  the  uterus.  Whether  these  be  com- 
monly of  the  same  kind  with  what  occasionally  grow 
in  the  placenta,  or  like  those  in  the  other  parts  of  the 
body,  I  cannot  determine,  as  it  has  not  occurred  to 
me  to  see  an  example  of  this  disease.  The  hydatids 
of  the  placenta  arc  a  good  deal  different  from  those  of 
the  liver,  kidneys,  and  some  other  parts  of  the  body. 

•  See  pheselden's  Anatomy  of  die  Bones,  plate  LVI. 
|  Vid.  Lieotaud,  Tom.  I.  p.  319.  p    ^V-.j. 

\  Dr.  Denman  bas  had  an  opportunity  of  observing  a  case,  where  watci 
was  accumulated  in  one  large  hydatid  ot  the  U  • 
§  Vid.  Licutaud,   Tom.  I..;. 


[     224     ] 

They  consist  of  vesicles  of  a  round  or  oval  shape, 
with  a  narrow  stalk  to  each,  by  which  they  adhere  on 
the  outside  of  one  another  Some  of  these  hydatids 
are  as  large  as  a  walnut,  and  others  as  small  as  a  pin's 
head.  A  large  hydatid  has  generally  a  number  of 
small  hydatids  adhering  to  it  by  narrow  processes. 
Of  their  real  nature  nothing  is  known,  but  they  are 
probably  animals  of  a  very  simple  structure.  In  the 
same  quadruped  sometimes  different  species  of  hyd- 
atids will  occur,  and  therefore  the  same  thing  may 
take  place  in  the  human  subject.  I  believe  that  the 
hydatids  said  to  be  found  in  the  uterus,  have  not  un- 
commonly been  only  hydatids  of  the  placenta,  which 
had  been  retained  there. 


Rupture  of  the  Uterus. 

These  are  the  various  diseased  appearances  which 
are  well  ascertained  to  take  place  in  the  uterus.  I 
have  to  add,  that  the  womb  is  not  unfrequently  rup- 
tured, which  is  rather  to  be  considered  as  an  accident 
than  a  disease.  This,  perhaps,  never  takes  place 
but  in  the  pregnant  uterus,  and  at  the  time  of  delive- 
ry. It  may  arise  either  from  too  violent  an  action  of 
the  muscular  fibres  of  the  uterus  upon  the  child,  or 
upon  the  hand  of  an  accoucheur,  who  may  for  some 
reason  or  other  have  introduced  it  into  its  cavity. 
The  ruptures  which  I  have  seen  have  been  commonly 
in  the  side  of  the  womb,  and  of  considerable  extent. 
The  peritonaeum  covering  the  womb  sometimes  re- 
mains whole,  and  there  is  a  large  mass  of  black  co- 
agulated blood  lying  between  it  and  the  uterus,  where 
the  rupture  has  taken  place.  This  black  uppearancc 
is  occasionally  mistaken  for  mortification. 


Two  Uteri. 

It  has  sometimes  happened,  although  very  rarely, 
that  two  uteri  have  been  formed  in  the  same  person 


[     225     ] 

instead  of  one.  In  this  case  there  is  but  one  ovari- 
um and  one  Fallopian  tube  to  each.  The  vagina  is 
at  the  same  time  divided  by  a  septum  into  two  ca- 
nals, e:.eh  of  which  conducts  to  its  proper  uterus. 
In  the  case  which  is  described  in  the  Philosophical 
Transactions,*  a  communication  was  formed  at  one 
part  through  the  septum  ;  but  how  far  this  generally 
takes  place  in  such  a  kind  of  monstrosity  I  cannot  de- 
termine. 


Natural  Varieties  in  the  Uterus. 

The  uterus  varies  a  good  deal  in  its  size  in  differ- 
ent persons,  in  some  being  fully  twice  as  large  as  it 
is  in  others.  It  differs  also  somewhat  in  the  thick- 
ness of  its  substance.  There  is  some  difference  too 
in  its  situation,  being  often  placed  nearer  one  side  of 
the  pelvis  than  the  other.  All  of  these  are  to  be  con-, 
sidered  as  varieties  in  the  natural  formation,  and  not 
as  disease. 


SYMPTOMS. 

In  inflammation  of  the  uterus,  there  is  a  sense  of 
pain  and  tension  in  the  hypogastric  region,  and  the 
pain  is  increased  upon  pressure  there,  or  upon  touch- 
ing the  os  uteri.  The  stomach  is  affected  with  vom-< 
iting,  and  the  bowels  are  sometimes  costive,  and 
sometimes  disposed  to  looseness.  The  whole  con- 
stitution is  roused  into  action,  exhibiting  those 
symptoms  which  have  been  called  fever,  and  the 
pulse  has  commonly  a  great  degree  of  frequency. 
When  the  peritoneum  is  inflamed  over  the  general 
surface  of  the  abdomen,  or  to  a  considerable  extent, 
there  is  a  general  swelling  of  that  cavity,  with  pain 

*  Sec  PUilosoph.  Trans.  Vol.  LXIV.  p.  -174. 

E  e 


and  extreme  tenderness  upon  pressure,  and  the  fever- 
ish  symptoms  are  increased. 


In  the  malignant  ulcer  of  the  uterus  there  is  a  sense 
of  pain  in  the  hypogastric  region ,  which  is  often  very 
violent.  At  the  same  time  there  is  commonly  felt  a 
dull  p  tin  round  the  hips  and  down  the  thighs.  Mu- 
cus, pus,  and  blood  are  frequently  discharged  by  the 
vagina,  and  the  quantity  of  blood  is  sometimes  very 
large.  The  pulse  at  the  beginniug  of  this  dreadful 
disease  is  natural  and  the  general  health  is  but  little 
impaired,,  but  when  it  is  far  advanced,  the  pulse  be- 
comes quick,  the  countenance  sallow,  and  the  body 
emaciated. 

If  in  the  progress  of  the  disease  a  communication 
should  be  formed  between  the  vagina  and  the  urina- 
ry bladder,  the  urine  will  then  pass  off  by  the  vagina* 
Some  of  the  glands  of  the  groin  in  advanced  stages 
of  the  disease  of._n  become  hard  and  enlarged  in  their 
size. 


In  the  scirrhous  enlargement  of  the  uterus,  there 
are  few  symptoms  to  characterise  it  till  the  disease 
has  made  considerable  progress.  There  is  pain  in 
•the  hypogastric  region  and  round  the  hips,  which  is 
more  or  less  acute  in  different  cases  ;  but  this  is  com- 
mon to  it  with  several  other  diseases.  When  the 
disease,  however,  is  a  good  deal  advanced,  it  may  be 
ascertained  by  an  examination  by  the  vagina.  The 
os  tincae  will  then  feel  enlarged  and  hard,  and  there 
will  be  an  unusual  sense  of  weight  against  the  finger 
from  the  increased  size  of  the  uterus.  A  tumour 
may  at  the  same  time  be  distinctly  felt  above  the 
pubes.  This  disease  is  commonly  attended  with 
mucous  discharges  from  the  vagina,  and  profuse  dis- 
charges of  blood  at  the  monthly  periods.     The  pulse 


[     227     ] 

is   generally  natural,  and  the  health  not  much  im- 
paired. 


When  tubercles  are  formed  in  the  \iterus,  and  the 
uterus  remains  of  its  natural  size,  there  are,  I  believe, 
no  symptoms  which  particularly  characterize  this  dis- 
ease. But  when  the  uterus  is  at  the  same  time  much 
enlarged,  the  symptoms  are  the  same  with  those 
which  belong  to  the  common  state  of  a  scirrhous  ute- 
rus, as  above  described. 


The  symptoms  which  attend  a  polypus  of  the  ute- 
rus, are  mucous  and  occasional  bloody  discharges  by 
the  vagina,  with  frequent  pains  round  the  hips. 
\Vhcn»  it  has  made  considerable  progress  in  its 
growth,  it  may  be  ascertained  by  an  examination  by 
the  vagina.  Even  without  this  examination,  it  may 
be  distinguished  from  an  ulcer  of  the  uterus,  by  at- 
tention to  the  history  of  its  progress,  and  by  the  gen- 
eral health  being  much  less  affected  in  this  case  than 
when  an  ulcer  has  been  formed.  The  glands  of  the 
.groin  are,  1  believe,  never  affected  from  a  polypus, 
but  are  often  tainted  by  absorption,  in  advanced  sta- 
ges of  the  ulcerated  uterus. 


When  there  is  a  part  of  the  fundus  uteri  inverted, 
forming  a  tumour  in  the  cavity  of  the  uterus,  there 
are  no  symptoms  by  which  it  can  be  sufficiently  dis- 
tinguished in  the  living  body.  It  is  attended  with  a 
profuse  hemorrhage,  and  if  the  patient  should  sur- 
vive, the  menstrual  flux  is  in  very  large  quantity,  to- 
gether with  very  copious  mucous  discharges  in  the 
intermediate  times.  When  the  inversion  is  complete, 
it  can  be  ascertained  by  an  examination  of  the  tumour, 
but  is  not  distinguished  by  any  peculiar  symptoms. 
The  attempts  which  have  been  made  to  return  the 


[     228     ] 

uterus  to  its  natural  situation,  have  almost  always 
been  unsuccessful. 


Prolapsus  uteri  can  always  be  ascertained  by  an 
examination,  and  the  exact  circumstances  attending 
this  case  cannot  be  ascertained  without  it. 


There  are  no  symptoms  by  which  dropsy  of  the 
uterus  can  be  distinguished  from  some  other  condi- 
tions of  this  organ,  and  therefore  it  is  only  known  in 
consequence  of  the  evacuation  of  the  water. 

There  will  of  course  be  more  or  less  enlargement 
of  the  uterus,  and  fulness  of  the  hypogastric  region, 
in  proportion  to  the  accumulation  of  the  water,  and 
this  will  subside  when  the  water  is  evacuated.. 


The  existence  of  hydatids  in  the  uterus  is  not  dis- 
tinguished by  any  characteristic  symptoms,  and  is 
only  known  in  consequence  of  their  expulsion,  by 
the  contractile  power  of  this  viscus.  This  generally 
takes  place,  and  is  attended  with  pains  resembling 
very  much  the  pains  of  labour. 


A  rupture  of  the  uterus  can  only  be  fully  ascertain- 
ed by  an  examination.  It  is  attended  with  pain,  with 
a  sense  of  something  having  given  way  in  the 
belly,  and  with  almost  an  immediate  vomiting  of  a 
chocolate-coloured  matter.  The  uterus  gives  up  its 
natural  efforts  for  the  expulsion  of  the  child,  so  that 
the  labour  pains  cease  ;  the  child  is  retracted,  and 
generally  escapes,  either  wholly  or  in  part,  into  the 
cavity  of  the  abdomen. 


[     229     ] 


CHAP.  XX. 


DISEASED     A  1'  I'  E  A  R  A  X  C  B  S    OF     THE    O  V  A  H  I  A . 


Inflammation  of the  Peritoneal  covering  of  the  Ovarlc. 


JL  HE  portion  of  the  peritonaeum  which  covers  the 
ovaria  I  believe  is  seldom  inflamed,  unless  where  the 
inflammation  has  spread  to  it  from  the  uterus,  or 
where  it  has  attacked  this  membrane  generally.  It  is 
not  unusual,  however,  for  it  to  be  inflamed  under  both 
of  these  circumstances  ;  and  it  shews  the  same  ap- 
pearances as  the  inflammation  of  the  peritonaeum 
covering  any  other  part.  Adhesions  too  are  frequent- 
ly found,  joining  the  ovaria  to  the  neighbouring 
parts,  which  had  been  the  consequence  of  such  an  in- 
flammation. 


Inflammation  of  the  substance  of  the  Ovaria. 

Where  the  uterus  has  been  inflamed  to  a  consider- 
able degree,  as  after  parturition,  the  substance  of 
the  ovaria  has  also  been  occasionally  attacked  by  the 
inflammation  spreading  to  it.  The  ovaria  are  then 
enlarged,  are  harder  than  in  a  natural  state,  and  are 
highly  vascular  ;  very  commonly  pus  is  found  to 
have  been  formed. 


Scirrhus  of  the  Ovaria. 

Scirrhus  is  a  disease   which  sometimes  attacks  the 
ovaria,  although  seldom  in  comparison  of   its  attack- 


[     230     ] 

zng  the  uterus.  Under  such  circumstances  the  ovarii 
become  enlarged,  and  are  converted  into-  a  whitish 
hard  mass,  which  is  more  or  less  intersected  with 
membranous  septa.  These  scirrhous  masses  have 
sometimes  a  disposition  to  be  converted  into  bone  ; 
and  in  this  way  most  frequently,  I  believe,  the  ova- 
ria  become  bony.  The  bony  substance  into  which 
they  are  converted  has  sometimes  a  greater  admix- 
ture of  earth  than  the  natural  bones  of  the  body. 

Ovaria  enlarged  and  changed  into  a  pulpy  Substance, 

The  ovaria  are  sometimes  very  much  enlarged, 
and  converted  into  pulpy  matter  of  a  smooth  uniform 
texture.  Cells  are  often  formed  in  a  part  of  this  sub- 
stance, which  contain  a  fluid. 


Ovaria  Scrofulous. 

The  ovaria  are  sometimes  changed  into  a  true  scrof- 
ulous matter,  intermixed  with  cells. 

Dropsy  of  the  Ovaria. 

The  most  common  disease  of  the  ovaria  is  dropsy. 
The  whole  substance  of  an  ovarium  is  sometimes  des- 
troyed, and  it  is  converted  into  a  capsule  containing 
a  fluid.  The  capsule  is  frequently  of  a  large  size  : 
it  consists  of  a  white  firm  membrane,  and  contains  an 
aqueous  fluid,  capable  of  being  partly  coagulated. 

When  the  substance  of  the  ovaria  is  destroyed,  and 
they  become  dropsical,  it  is  very  common  for  them 
to  be  converted  into  a  number  of  cells,  which  com- 
municate with  each  other  by  considerable  openings, 
and  to  be  prodigiously  enlarged.  An  ovarium  in  this 
case  may  be  so  increased  in  size  as  to  occupy  almobt 
the  whole  cavity  of  the  abdomen.  The  ovaria  are 
also  sometimes  converted  into  a  congeries  of  cysts, 
which   have    no    communication   with   each  ether. 


[     231     ] 

These  vary  a  good  deal  in  their  size,  some  being  not 
larger  than  a  hazel  nut,  and  others  as  large  as  an 
orange.  Their  coats  are  sometimes  thin,  sometimes 
of  considerable  thickness,  and  consist  of  a  compact, 
white,  laminated  membrane.  They  contain  cither  a 
serous  fluid,  with  which  I  have  seen  some  slimy  mat- 
ter mixed,  or  a  thick  ropy  fluid,  or  a  kind  of  jelly. 
This  jelly  is  sometimes  so  tough  that  it  can  be  drawn 
out  to  a  considerable  length,  and  when  it  breaks,  it 
passes  back  with  a  great  deal  of  elastic  force.  Diffe- 
rent cysts  in  the  same  ovarium  will  sometimes  con- 
tain different  sorts  of  fluid,  a  circumstance  which  one 
woukl  not  expect  a  priori. 

These  cysts,  I  believe,  have  been  occasionally  con- 
founded with  hydatids,  to  which  they  hear  some  re- 
semblance. They  are  however  really  very  different. 
They  have  much  firmer  and  less  pulpy  coats  than 
hydatids ;  they  contain  a  different  kind  of  fluid, 
and  they  are  differently  connected  among  them- 
selves. Hydatids  either  lie  unconnected  witli 
each  other,  or  a  large  hydatid  incloses  a  number  of 
smaller  ones  ;  or  smaller  hydatids  adhere  to  the  coats 
of  those  which  are  larger.  Cysts  of  the  ovarium  ad- 
here to  each  other  laterally  by  pretty  broad  surfaces  ; 
do  not  inclose  each  other  ;  and  appear  to  have  no 
power  analogous  to  generation  as  hydatids  have,  by 
which  smaller  cysts  are  formed,  that  are  attached  to 
those  of  a  larger  size.  It  appears  not  improbable, 
that  these  cysts  are  formed  by  a  gradual  enlargement 
of  the  small  vesicles  which  make  a  part  of  the  natural 
structure  of  the  ovaria. 

The  Ovaria  changed  into  a  fifty  Substance  with  Hair 
and  Teeth. 

The  ovaria  are  sometimes'convertcd  into  a  fatty  sub- 
stance, intermixed  with  long  hair  and  teeth,  which 
is  surrounded  by  a  capsule  consisting  of  a  white  strong 
membrane.  The  hairs  are  most  of  them  loose 
in  the  fatty  substance,  but  many  of  them  also  adhere 


[     232     ] 

on  the  inside  of  the  capsule.  Teeth  too  are  formed, 
but  are  generally  incomplete,  the  fangs  being  want- 
ing. These  sometimes  arise  immediately  from  the 
inner  membrane  of  the  capsule,  and  are  sometimes 
connected  with  an  irregular  mass  of  bone.  Such 
productions  have  been  commonly  considered  as  very 
imperfect  ova,  in  consequence  of  impregnation  ;  but 
there  is  good  reason  to  believe  that  they  can  take 
place  without  any  intercourse  between  the  sexes.  J 
have  described  a  case,  which  has  been  published  in 
the  Philosophical  Transactions,  where  it  was  hardly 
possible  that  impregnation  could  have  happened. 
The  girl  in  whom  this  change  of  the  ovarium  was 
found  could  not  from  all  appearances  have  been  more 
than  twelve  or  thirteen  years  old  ;  the  hymen  was 
perfect  ;  and  the  uterus  had  not  received  that  increase 
of  bulk  which  is  usual  at  puberty.  The  other  marks 
of  puberty  were  also  wanting.  From  these  circum- 
stances I  should  judge  the  womb  to  have  been  inca- 
pable of  the  stimulus  of  impregnation.  A  tumour, 
consisting  of  teeth  and  hair,  was  preserved  by  the 
celebrated  Ruysch*  in  his  collection,  which  he  says 
was  found  in  a  man's  stomach.  If  this  be  true 
(which  there  seems  to  be  no  reason  to  doubt,)  it  puts 
my  conjecture  beyond  dispute.  This  production 
could  not  possibly,  under  such  circumstances,  have 
any  connection  with  impregnation  ;  and  if  it  occurs 
without  it  in  one  part  of  the  body,  there  can  be  no 
good  reason  why  it  may  not  also  take  place  without 
impregnation  in  another  part.  These  productions 
are  much  more  frequent  in  the  ovaria  than  any  where 
else,  probably  because  the  process  which  forms  them 
bears  some  analogy  to  generation,  in  which  the 
ovaria  are  materially  concerned.  I  must  still  there- 
fore, whatever  objections  have  been  made  to  it,  retain 

•  Vid.  lluyschtTomlI.  Adversar-  Anatomicor,  Decad.  tcrt. 


f     234     ] 

tny  former  opinion.     These  masses  in  the  ovaria  are 
commonly  about  the  size  of  a  large  orange  * 

*  I  have  very"  lately  met  with  the  same  kind  of  fatty  substance 
intermixed  with  hair,  and  the  body  of  one  tooth  covered  with  en- 
amel, in  tlie  o-jfiumofa  young  woman  about  eighteen  years  of 
age.  In  this  case  the  uterus  was  rather  less  than  its  usual  size  in 
the  adult  when  unimpregnated,  and  there  was  no  membrana  de- 
cidua  whabet  :r  formed  in  its  cavity.  It  appeared,  therefore,  to 
be  undergoing  no  change  similar  to  what  happens  when  there  is 
an  ovum  growing  in  the  ovarium  or  the  Fallopian  tube.  The  hy- 
men too  was  perfect,  the  edge  of  the  membrane  being  quite  sound 
and  natural,  and  the  aperture  in  it  being  remarkably  small.  These 
circumstances  do  not  amount  to  demonstrative  evidence,  but  still 
must  be  considered  as  a  very  strong  confirmation  of  the  truth  of 
the  opinion  above  stated. 

I  have  been  informed  by  Mr.  Colnian,  that  a  dead  gelding  was 
sorm*  time  ago  examined,  in  which  a  cyst  was  found  a  little  under* 
the  right  kidney,  containing  a  fatty  matter,  hair,  and  some  teeth. 
This  fully  establishes  the  truth  of  the    opinion  above  stated. 

The  particulars  discovered  by  dissection  are  very  curious,  and 
are  so  clearly  stated  by  Mr.  C  el  man,  that  1  shall  take  the  liberty 
of  subjoining  the  account  of  them  in  his  own  words  : 

u  A  bay  gelding,  seven  years  old,  belonging  to  ihr  Royal  Horse 
Artillery  at  Woolwich,  was  attacked  with  a  contagious  and  incu- 
rable disease,  (viz.  glanders)  in  consequence  of  which  I  recom- 
mended that  the  horse  should  be  destroyed.  After  the  morbid 
parts  concerned  in  this  disease  had  been  examined,  Mr.  Percjvall. 
Veterinary  Surgeon  to  the  most  honourable  Board  of  Ordnance? 
•;e  attention  to  anatomy  and  his  profession  in  general  deserves 
the  highest  encomiums)  accidentally  opened  the  cavity  of  the  ab- 
domen, and  discovered  a  tumour  about  the  size  of  a  horse's  testi- 
cle, of  an  oblong  form,  a  little  below  the  right  kidney,  and  loosely 
attached,  by  p  long:  slender  neck,  to  the  peritonaeum.  Mr.  Perci- 
vall  removed  this  tumour  without  supposing  that  the  contents 
were  peculiar,  but  as  the  inner  parts  felt  as  if  they  were  of  a  bony- 
nature,  a  longitudinal  section  was  made  with  a  saw  completely 
through  its  substance.  It  now  appeared  that  the  outer  cyst  of 
the  tumour  contained  two  small  molar  horse-teeth,  and  one  inci- 
sor toothy  with  a  portion  of  bone  attached  to  this  tooth  resembling 
the  jaw.  The  remainder  of  the  tumor r  was  composed  of  about 
two  thirds  of  fat,  and  one  third  of  hair  of  a  black  colour  contain^ 
edin  a  separate  cyst.  The  molar  teeth,  which  were  fortunately 
ded  by  the  saw  longitudinally  Dear  the  centre,  had  the  same 
ngement  of  enai  L  bony  matter  aft  natural  horse's  teeth. 

Two  very  'small  blood  vessels  were  observed  going  from  the  I 
©f  the  tumour  into  its  substance,  but   they   were  not  attended  to, 
:e  section  had  been  made.  As  the  history  of  the  animal  I  an 

F  f 


[     235     ] 

A  Fcetus  in  the  Ovarium. 

A  fastus  is  sometimes  found  in  the  ovarium. — 
This  seldom  arrives  at  the  full  size,  but  its  formation 
as  far  as  it  goes  is  commonly  perfect.  When  this 
happens,  all  vestige  of  the  ovarium  is  lost,  and  in- 
stead of  it  there  is  a  bag  of  some  firmness  containing 
the  foetus  ;  to  this  bag,  upon  the  inside,  is  attached 
a  placenta,  and  a  part  of  the  chorion.  The  bag  can 
be  ascertained  to  be  the  ovarium,  by  tracing  upon  it 
the  Fallopian  tube  and  the  spermatic  vessels,  from 
their  origin  to  their  termination.  The  uterus  in  such 
cases  is  considerably  larger  than  when  unimpregna- 
ted,  and  in  its  cavity  there  is  formed  the  membrana 
decidua.  This  shews  that  the  uterus  takes  on  the 
same  changes,  although  imperfectly,  which  it  does 
in  the  ordinary  circumstances  of  pregnancy.  The 
spermatic  vessels  are  also  enlarged,  in  order  to  sup- 
ply a  sufficient  quantity  of  blood  to  the  ovum  which 
is  growing  in  the  ovarium. 

Shrinking  of  the  Ovarta. 

The  ovaria  commonly  shrink  towards  old  age,  and 
are  changed  in  their  structure.  They  are  diminish- 
ed to  half  their  natural  size,  are  somewhat  tubercu- 
lated  on  their  surface  and  are  hard.  When  cut  into, 
the  vesicles,  which  make  a  part  of  their  natural  struc- 
ture, are  found  to  be  filled  with  a  white  solid  matter. 

its  birth  could  not  be  procured,  it  cannot  be  ascertained  whether 
both  testicles  had  previously  been  removed.  It  is  possible  that 
one  testicle  might  have  remained  in  the  abdomen,  and  the  form, 
situation,  and  sizs  of  the  tumour,  rather  favour  this  supposition. 
But  whether  blood  vessels  were  formed  from  the  neighbouring 
parts  to  produce  this  peculiar  organization,  or  whether  the  teeth 
and  hair  were  produced  by  the  spermatic  vessels,  the  process  is 
equally  curious  and  inexplicable.  This  phenomenon,  however, 
fully  establishes  the  opinion  of  Dr.  Baillie,  that  when  teeth  arid 
hair  and  fat  are  found  in  the  ovaria,  impregnation  i;>  not  necessa- 
ry to  their  formation,  and  therefore  it  is  highly  probable,  that  in 
no  instance  it  has  been  the  cause  of  these  extraordinary  produc- 
tions in  the  ovaria." 


[     236     ] 

One  Ovarium  or  both  wanting. 

An  ovarium  on  one  side  has  been  known  to  be 
wanting  ;  but  this  is  extremely  rare.  An  example 
of  this  kind  is  preserved  in  Dr.  Hunter's  collection. 
Some  instances  have  been  recorded,  in  which  no 
vestige  of  an  ovarium  could  be  observed  on  either 
side. 


SYMPTOMS. 

As  the  ovaria  are  very  seldom  inflamed,  unless 
when  inflammation  has  at  the  same  time  attacked  the 
uterus  ;  it  is  not  known  whether  there  be  any  partic- 
ular symptoms  which  characterize  inflammation  of 
the  ovarii.  Inflammation  of  the  ovaria  cannot  at 
present  be  distinguished,  by  its  symptoms  from  in- 
ilammation  of  the  uterus. 


A  scirrhous  state  of  the  ovaria,  is  with  difficulty 
determined  in  the  living  body.  When  a  scirrhous 
ovarium  has  increased  to  a  large  size,  and  lies  upon 
the  side  of  the  pelvis,  and  the  person  is  at  the  same 
time  of  a  spare  habit,  it  may  in  some  measure  be  as- 
certained by  an  accurate  examination  of  the  tumour 
through  the  parictes  of  the  abdomen.  The  tumour 
will  feel  much  harder  than  where  an  ovarium  is  en- 
larged by  dropsy,  or  fdled  with  cysts.  When  the 
ovarium  is  not  capable  of  being  accurately  examined, 
the  opinion  about  the  existence  of  this  disease  must 
rest  much  more  upon  probable  evidence  than  upon  any 
clear  proof. 


Dropsy  of  the  ovarium  cannot  be  ascertained  in  a 
very  early  stage  of  this  disease.  But  when  it  has 
made  considerable  progress,  so  as  to  have   formed  a 


[     237     J 

swelling  at  the  lower  part  of  the  belly,  it  may  com- 
monly be  ascertained  by  an   accurate  examination, 
and  attention  to  the  history  of  its  growth.     The  tu- 
mour is  generally  on  one  side  of  the  abdomen  more 
than  the  other,  according  as  the  right  or  left  ovarium 
is  affected.     There  is  often  an  inequality  in  the  sur- 
face of  the  swelling,  and  an  obscure  kind  of  fluctua- 
tion ib  felt,  upon  striking  with  the  hand  the   parietes 
of  the   abdomen,  which  cover    the  swelling.     The 
health  is  commonly  very  little  affected  by  this  disease, 
and  it  is   slow  in  its  progress,  so  that  life  will  often 
be  continued  with  tolerable  comfort  under  it  for  ma- 
ny years.     The  quantity  of  the  urine  is  often  but  lit- 
tle diminished  below  what  is  usual  in  health,  and  the 
absorbents  of  the  ovarium  are  hardly  capable  of  being 
excited  to  a  vigorous  action  by  medicine      There 
have  been  few  instances,  therefore,  of  a  dropsy  of 
the  ovarium  being  cured, 


C     238     j 
CHAP.   XXL 


0I-SEASE13        APFEARAVCES      OF      THS     FALLOP 

TUBES. 


PIAtf 


Inflammation  of  the  Fallopian  Tubes. 


w 


HEN  the  uterus  is  inflamed  to  a  considerable 
degree,  the  inflammation  often  spreads  along;  theFal- 
lopiaittubes  :  they  become,  in  this  case,  highly  vas- 
cular, and,  when  cut  open,  sometimes  contain  blood 
in  their  cavities.  The  inflammation  may  even  ad- 
vance to  suppuration,  when  their  cavities  will  fc>e 
found  loaded  with  pus. 

v  Adhesions. 

When  the  peritonaeum  generally,  or  some  part  of 
it,  in  the  neighbourhood  q{  the  Fallopian  tubes,  is 
inflamed,  the  external  covering  of  these  tubes,  which 
is  a  continuation  of  the  peritoneum,  also  partakes  of 
the  inflammation.  This,  when  it  subsides,  gener- 
ally terminates  in  adhesions  of  the  Fallopian  tubes  to 
the  contiguous  parts.  It  is  not  unusual  to  find  the 
fimbriated  extremity  of  the  Fallopian  tubes  adhering 
to  the  pvaria  ;  or  when  the  previous  inflammation  has 
been  considerable,  to  find  the  fimbriated  appearance 
entirely  lost,  and  the  body  of  the  Fallopian  tube  ap- 
parently terminating  on  the  surface  of  the  ovarium. 
Under  such  circumstances  there  is  no  aperture  to- 
wards this  end  of  the  Fallopian  tubes,  and  it  has  lost 
its  power  of  conveying  the  ovum  from  the  ovarium 
to  the  uterus. 

The  very  small  aperture  by  which  the  Fallopian 
tube  communicates  with  the  cavity  of  the  uterus,  is 
sometimes  obliterated,  but  not  so  often  as  the  aper- 
ture of  that  extremity  next  to  the  ovarium. 


[     239     ] 

Dropsy  of  the  Fallopian  Tubes. 

When  the  Fallopian  tube  has  its  apertures  closed 
at  both  extremities,  it  is  sometimes  dilated  into  a 
considerable  tortuous  cavity.  This  when  laid  open 
appears  occasionally  subdivided  by  small  partial  sep- 
ta, and  contains  an  aqueous  fluid,  which  is  capable 
of  being  partly  coagulated.  This  fluid  is  undoubt- 
edly supplied  by  the  secretion  of  the  small  arteries 
belonging  to  the  inner  membrane  of  the  Fallopian 
tube,  which  is  naturally  very  vascular.  It  may  be 
called  dropsy  of  the  Fallopian  tube. 

The  Fallopian  tubes  terminating  in  a  Cul-de-sac. 

The  Fallopian  tubes  I  have  seen  without  any  aper- 
ture or  fimbriated  extremity,  from  a  defect  in  the 
original  formation,  and   terminating  in  a  cul-de-sac. 

Under  such  circumstances  they  were  incapable  of 
performing  their  oflice  as  subservient  to  generation. 

An  Ovum  in  the  Fallopian  Tube. 

The  Fallopian  tube  is  sometimes  dilated  into  a  bag 
containing:  an  ovum.  This  arises  from  the  ovum  be- 
ing  stopped  in  its  progress  from  the  ovarium  to  the 
uterus.  When  it  is  so  stopped  it  docs  not  die,  but 
is  gradually  evolved  as  if  it  had  been  lodged  in  the 
cavity  of  the  uterus.  This,  among  many  others,  is 
a  proof  that  the  uterus  is  not  the  only  organ  which 
is  fitted  to  evolve  an  ovum,  but  that  other  parts  of 
the  body  can  perform  this  office.  While  the  ovum 
is  enlarging,  the  Fallopian  tube  is  more  and  more 
dilated,  forming  a  thin  bag  round  the  ovum.  The 
blood  vessels  passing  to  the  ovarium,  and  the  Fallo- 
pian  tube  where  the  ovum  is  contained,  are  gradu- 
ally enlarged,  in  proportion  to  the  increase  of  the 
ovum,  in  order  to  supply  it  with  a  sufficient  quantity 
of  blood.  While  this  process  is  going  on  in  the 
Fallopian  tube,  the  uterus  increases  in  bulk  so  as  to 
be  fullv  twice   its  natural   size,  and  becomes  more 


I     240     ] 

vascular.  The  cavity  of  its  fundus  is  also  lined  with 
a  membrana  decidua,  and  the  cervix  uteri  is  plug- 
ged up  with  jelly.  The  uterus  therefore  undergoes 
a  variety  of  changes,  exactly  similar  to  what  take 
place  in  natural  pregnancy,  being  thrown  into  this 
mode  of  action  from  the  original  stimulus  of  impreg- 
nation. The  ovum  sometimes  makes  considerable 
progress  in  the  Fallopian  tube,  and  has  been  known 
to  advance  even  to  the  full  period  of  gestation  ;  but 
more  commonly  it  dies  at  an  early  period.  In  the 
course  of  the  evolution  of  the  ovum,  the  Fallopian 
tube  has  been  known  to  rupture,  and  the  person  to 
die  from  internal  haemorrhage.  A  very  clear  and 
accurate  account  of  such  a  case  has  been  published 
by  Dr.  Clarke,  in  the  Medical  and  Chirurgical  Trans- 
actions.* 

Hard  Tumour  growing  from  a  Fallopian  Tube. 

I  have  seen  a  hard  round  tumour  growing  from  the 
outer  surface  of  one  of  the  Fallopian  tubes.  This 
when  cut  into  exhibited  precisely  the  same  appear- 
ance of  structure  as  the  tubercle  which  grows  from 
the  surface  of  the  uterus,  viz.  it  consisted  of  a  hard 
white  substance,  which  was  intersected  by  strong 
membranous  septa.  This,  however,  I  believe  to  be 
a  very  rare  appearance  of  disease. 

Diseased  appearances  of  the  round  Ligaments. 

The  round  ligaments  partake  of  the  inflammation 
of  the  uterus,  when  it  is  considerable,  and  has  spread 
to  its  appendages.  They  are  also,  doubtless,  sub- 
ject to  other  diseases,  but  these  are  very  rare,  and 
have  not  fallen  under  my  own  observation,  nor  do  I 
know  of  their  having  been  particularly  taken  notice 
of  by  authors. 

•  See  p.  2*1     V»l 


I     241     3 


SYMPTOMS, 


The  symptoms  which  attend  the  different  morbid 
changes  of  the  Fallopian  tubes  are  at  present  not 
known ;  and  they  must,  from  the  circumstances  be* 
longing  to  them,  be  very  difficult  to  ascertain. 


C     241     J 
CHAP.  XXII. 

* 

BISEASED    APPFARANCES     OF   THE    VAGINA. 

Inflammation  of  the  Vagina. 


T 


HE  internal  surface  of  the  vagina,  near  the 
outward  opening,  is  frequently  inflamed,  especially 
from  the  application  of  the  venereal  poison,  but  this 
hardly  ever  becomes  the  subject  of  examination  after 
death. 

Adhesion  of  the^Sides  of  the  Vagina. 

A  very  violent  inflammation  has  sometimes  been 
known  to  take  place  in  the  vagina,  which  has  termi- 
nated in  the  mutual  adhesion  of  the  sides  of  the  cav- 
ity. This  adhesion  is  sometimes  extended  over  a 
great  part  of  the  cavity,  but  I  believe  is  often  more 
confined,  producing  a  stricture  in  some  one  part. 

Ulcers  of  the  Vagina. 

Ulcerations  are  not  unusual  in  the  vagina.  They 
sometimes  appear  like  spots  of  the  internal  surface, 
removed  as  it  were  by  a  knife,  and  sometimes  there 
is  a  foul  ragged  ulcer.  When  this  last  is  the  case  in 
any  considerable  degree,  the  ulcer  has  commonly 
not  originated  in  the  vagina,  but  has  spread  to  it 
from  the  womb.  When  the  ulcer  spreads  very  much, 
communications  are  often  made  with  the  neighbour- 
ing parts,  producing  a  most  miserable  state  of  exist- 
ence. Thus  communications  are  sometimes  formed 
between  the  vagina  and  the  rectum,  or  the  vagina 
:i::d*  the  bladder. 

G  g 


[     242     ] 

Scirrhous  Tumours  in  the  Vagina. 

Scirrhous  tumours  occasionally  arise  in  the  vagina 
itself  (although,  I  believe,  rarely)  when  the  uterus  is 
unaffected.  When  cut  into,  they  exhibit  the  usual 
scirrhous  structure  which  has  been  often  described. 

Inversion  of  the  Vagina. 

One  of  the  most  common  diseases  of  the  vagina  is 
its  inversion,  or  prolapsus  :  this  is  more  apt  to  happen 
where  the  natural  formation  of  the  pelvis  is  large, 
where  the  external  opening  at  the  vulva  is  wide,  and 
where  the  parts  are  generally  relaxed.  The  prolap- 
sus is  more  or  less  in  different  cases  ;  in  some  the 
uterus  does  not  pass  out  at  the  external  parts,  and  in 
others  the  inversion  of  the  vagina  is  complete,  at  the 
extremity  of  which  is  situated  the  os  uteri.  The  pro- 
trusion has  then  different  shapes  ;  it  sometimes  forms 
a  large  rounded  mass,  and  sometimes  it  is  narrower 
and  more  elongated,  extending,  perhaps,  five  inches 
from  the  surface  of  the  body.  When  this  last  has 
been  the  ease,  it  has  been  sometimes  mistaken  for 
that  species  of  monstrous  formation  called  hermaph- 
rodite. We  may  here  take  aw  opportunity  of  men- 
tioning, that  although  in  some  of  the  common  quad- 
rupeds a  real  hermaphrodite  structure  has  occasion- 
ally been  found,  yet  it  has  hardly  ever  occurred  in  the 
human  subject.*     When  the  vagina  has   been  long 

*  Although  the  examples  nf  what  have  been  called  hermaphrodites 
in  the  human  species  have,  when  strictly  examined,  been  hitherto 
found  to  belong  to  ihe  male  or  the  female  sex  ;  yet  Dr.  Storer  of 
Nottingham  has  favoured  me  with  an  account  of  a  person  so 
strongly  marked  as  a  hermaphrodite,  that  no  doubt  can,  1  think, 
be  reasonably  entertained  of  this  being  the  case.  The  person  to 
whom  tliis  singular  monstrosity  belongs,  is  still  alive,  and  ban 
been  carefully  examined  by  Dr  Storer  and  other  medical  gentle- 
men, very  able  to  judge  concerning  it  ;  I  shall  therefore  take  the 
liberty  of  inserting,  here,  the  account  which  Dr.  Storer  was  so 
obliging"  as  to  send  me. 

The  person  bears  a  woman's  name,  and  wears  the  apparel  of  a 
**om;:n.     Sb,e  has  a   remarkable  masculine  look,  with  plain   fea 


I  m  ] 

subject  to  inversion,  its  inner  surface  becomes  in  ma- 
ny parts  harder  ;  it  is  apt  to  be  occasionally  inflamed 
from  external  irritation,  which  not  uncommonly  ad- 
vances to  ulceration. 

In  inversion  of  the  vagina  and  prolapsus  of  the 
uterus,  if  the  cavity  of  the  pelvis  be  examined,  the 
fundus  only  of  the  uterus  can  be  seen  with  its  appen- 
dages very  imperfectly,  or  the  whole  of  the  uterus  is 
hid  entirely  :  the  bladder  then  appears  to  be  in  con- 
tact with  the  rectum.  In  this  state  of  the  uterus  and 
its  appendages,  I  have  known  adhesions  formed  be- 
tween them  and  the  neighbouring  parts.  These  must 
have  rendered  the  reduction  of  the  uterus  and  the  va- 
gina into  their  natural  situation  very  difficult,  and  per- 
haps, till  the  adhesions  were  a  good  deal  elongated, 
impossible. 


The  Vagina  very  short* 

The  vagina  is  sometimes  very  short.  I  have  seen, 
it,  not  more  than  half  its.  natural  length.  This  is  an 
original  defect  in  the  formation  of  the  part,  and  can 
only  be  ascertained  by  an  examination. 

tures,  but  no  beard.  She  had  never  menstruated  ;  and  on  this 
account  she  was  desired  by  the  lady  with  whom  she  lived  as  ser- 
vant, to  become  an  out-patient  at  the  Nottingham  Hospital.  At 
this  time  she  was  twenty  four  years  of  age,  and  had  not  been 
sensible  of  any  bid  health,  but  only  came  to  the  hospital  in  order 
to  comply  with  the  wishes  of  her  mistress.  Various  medicines 
were  tried  without  effect,  which  led  to  the  suspicion  of  the  hy- 
men being  imperforated}  and  the  menstrual  blood  having  accu- 
mulated behind  it.  She  was,  therefore,  examined  by  Mr.  Wright, 
one  of  the    surgeons  to  the  hospital,  and  by  Dr.  Store r.  . 

The  vagina  was  found  to  terminate  in  a  cul-dc-sac,  two  inches 
from  the  external  surface  of  the  labia.  The  head  of  the  clitoris, 
and  the  external  orifice  of  the  meatus  urinx,  appeared  as  in  the 
natural  structure  of  a  female,  but  there  were  no  nymphs.  The 
labia  were  more  pendulous  than  usual,  and  contained  each  of 
them  a  body  resembling  a  testicle  of  a  moderate  size,  with  it  a 
chord.  The  mammae  resembled  those  of  a  woman.  The  person 
' i  .i <J  no  desire  or  partiality  whatever  for  either  sex, 


E     244     ] 

The  Vagina  widened. 

The  vagina  is  sometimes  very  much  stretched  Oi* 
■widened  by  large  tumours  which  are  lodged  in  it  . 
these  are  chiefly  polypi  ;  and  when  they  have  been 
removed  by  art,  the  vagina,  if  it  has  not  been  For  a 
long  time  stretched,  recovers  nearly  its  natural  size^ 

The  Vagina  very  narrow. 

The  Vagina  has  occasionally  been  found  to  be  very- 
much  contracted  with  regard  to  its  transverse  diame- 
ter, from  a  defect  in  the  original  formation.  Thisj 
however,  occurs  very  rarely,  and  may  in  some  degree 
be  remedied  by  art. 


SYMPTOMS. 

The  symptoms  which  attend  inflammation  cf  the 
inner  membrane  of  the  vagina,  and  the  labia,  are  too 
well  known  to  require  any  description. 


An  adhesion  of  the  sides  of  the  vagina  can  only  be 
distinctly  known  by  an  examination.  It  may,  how- 
ever, be  strongly  suspected  where  there  has  been  a 
previous  violent  inflammation  of  the  vagina,  and  since 
that  period  there  has  been  no  menstrual  discharge,  to- 
gether with  an  unfitness  for  the  usual  intercourse  be- 
tween the  sexes.  When  the  adhesion  has  extended 
over  a  considerable  part  cf  the  vagina,  it  is  hardly 
possible  by  an  operation  to  separate  the  adhering  sur. 
faces,  and  to  restore  the  original  canal.  I  have  known 
attempts  of  this  kind  to  fail  in  the  most  skilful 
hands  ;  and  it  requires  much  nicety  of  management 
to  avoid  making  an  opening  into  the  bladder  or  the 
rectum.  Where  the  extent  of  the  adhesion  is  small, 
H  is  very  capable  of  being  remedied  by  an  operation! 


I     245     ] 

except  perhaps  very  near  the  internal  extremity  of 
the  vagina.  As  it  is  impossible,  when  the  adhesion 
Is  complete,  to  know,  a  priori,  whether  it  be  of  large  or 
of  small  extent,  it  is  almost  always  proper  to  attempt 
an  operation  ;  but  this  should  only  be  done  by  a  sur- 
g.-on  who  is  dexterous  in  the  management  of  the 
knife,  and  with  extreme  caution.  When  there  is 
merely  a  narrow  line  of  adhesion,  this  may  probably 
be  discovered  by  the  accumulation  of  the  menstrual 
blood  behind  it  ;  and  it  is  possible  that  this  accumula- 
tion may  at  length  break  through  the  adhesion,  and 
render  an  operation  unnecessary.  It  would  be  absurd 
however,  to  put  off  an  operation  which  under  such 
circumstances  must  be  very  slight,  for  the  very  un* 
certain-chance  of  this  effect  taking  place. 


Ulcers  in  the  vagina  can  only  be  determined  with 
accuracy  by  an  examination  of  that  passage  in  the  liv- 
ing bod)*.  They  are  attended  with  more  or  less  pain, 
and  with  a  discharge  of  pus  ;  but  both  of  these  symp- 
toms belong  also  to  inflammation  of  the  vagina,  with* 
t>ut  any  ulceration  whatever. 


An  inversion  of  the  vagina  is  attended  with  a  sense 
bf  bearing  down  (as  patients  commonly  express  it,» 
and  a  tumour  passes  outwards  through  the  vulva, 
more  especially  in  an  erect  posture.  The  exact  cir- 
cumstances of  the  disease  can  only  be  ascertained  by 
an  examination  in  the  living  body. 


The  existence  of  tumours  growing  in  the  vagina 
can  only  be  accurately  ascertained  by  an  attentive  ex- 
amination. 


[     246     ] 
CHAP.  XXIII. 


DISEASED       AND    PRETERNATURAL    APPEARANCES 
OF     TiiE  EXTERNAL     PARTS. 


The  Hymen  imperforated. 


T 


HE  hymen  is  sometimes  found  without  a  per- 
foration in  it,  so  that  the  vagina  is  completely  shut 
up  at  its  external  extremity.  This  is  an  original  mal- 
formation, which  is  frequently  not  discovered  till  the 
age  of  puberty,  when  the  menstrual  blood  is  accumu- 
lated behind  it.  It  is  of  little  consequence,  as  it  can 
be  easily  remedied  by  a  slight  operation. 

The  Clitoris  enlarged. 

An  enlarged  clitoris  is  also  a  natural  deformity,  less 
common  than  the  other,  but  a  more  unfortunate  one. 
At  birth,  the  clitoris  in  such  a  case  is  often  larger 
than  the  penis  of  a  male  child  of  the  same  age.  It 
has  a  well  formed  prepuce  and  glans,  together  with 
a  fissure  at  its  extremity,  so  as  to  resemble  almost 
exactly  the  external  appearance  of  the  male  organs. 
These  cases  have  given  rise  to  a  mistake,  with  regard 
to  the  sex,  and  females  have  been  often  baptized  for 
males.  On  most  occasions,  however,  where  there 
is  an  enlarged  clitoris,  the  sex  may  be  determined  by 
the  following  circumstances.  The  labia  are  well 
formed,  and  when  handled,  no  round  bodies  are  felt 
in  them,  like  the  testicles.  The  fissure  at  the  ex- 
tremity of  the  glans  does  not  lead  to  any  canal  of  the 
urethra  ;  but  under  the  glans,  and  at  the  posterior 
extremity  of  the  fissure,  there  is  an  opening  which 
leads  immediately  to  the  bladder.  1  should  believe, 
that  by  putting  a  small  straight  probe  into  this  orifice, 
and  passing  it  into  the  bladder,  it  could  be   at  once 


[     247     ] 

determined,  on  most  occasions,  whether  the  child 
was  male  or  female.*  If  the  child  should  live  to  grow 
up,  the  clitoris  enlarges,  but,  I  believe,  not  in  the 
same  proportion  as  the  penis  would  do.  Such  cases 
have  been  often  mistaken  for  hermaphrodites. 

The  ]\ymphcc  enlarged. 

The  nymphae  are  not  uncommonly  enlarged  be- 
yond their  natural  si2e.  This  sometimes  happens  to 
one  only,  and  sometimes  to  both.  When  the 
nymphae  are  very  much  enlarged,  they  pass  consid- 
erably beyond  the  surface  of  the  body,  and  have  the 
same  sort  of  covering  with  the  labia,  losing  by  their 
exposure  the  fine,  vascular,  sensible  covering  of  the 
natural  nymphse.  This  is  a  monstrous  formation  of 
no  great  consequence,  unless  the  enlargement  be  ex- 
cessive, and  even  then  the  nymphae  can  be  extirpa 
ted  by  art. 

The  external  Labia  growing  together. 

The  two  external  labia  are  sometimes  united  to- 
gether by  a  fine  line  of  junction,  at  the  upper  end  of 
which  are  situated  the  meatus  urinae,  and  the  glans 
of  the  clitoris.  This  sort  of  monstrous  formation  is 
not  at  all  common,  and  is  very  easily  remedied. 
When  the  external  labia  are  separated  by  a  slight  op- 
eration, all  the  parts  behind  are  found  perfect. 

The  two  labia  are  sometimes  joined  together  by  a. 
continuation  of  the  common  skin,  so  that  the  appear- 
ance of  labia  is  lost  entirely.  This  defect  may  also 
be  remedied  by  art,  and  the  parts  within  will  be 
found  to  be  well  formed. 

•  Supposing  the  child  to  be  a  female,  the  probe  will  -pass  readily  through 
a  short  straight  canal  ;  but  supposing  it  to  be  a  male,  the  probe  will  neither 
pass  in  a  straight  direction,  nor  without  some  degree  of  curvature  being  given 
to  us  shape,  and  the  canal  will  be  found  to  be  of  a  considerable  length. 


C     248     ] 


The  external  parts,  particularly  the  inside  of  the 
nymphs,  and  the  vestibulum,  are  subject  to  inflam- 
mation and  ulcers  from  common  causes,  and  espe- 
cially from  the  application  of  the  venereal  poison. 
These  diseases,  although  they  are  very  often  the 
subject  of  solicitude  during  life,  yet  are  seldom  ex- 
amined after  death,  and  therefore  we  shall  omit  them 
here  altogether. 


It  is  unnecessary  to  subjoin  any  account  of  symp- 
toms to  this  chapter. 


./• 


£    249     ] 


CHAP.  XXIV. 


DISEASED     APPEARANCES   OF     THE    BRAIN    AND   ITS 
MEMBRANES. 


Inflammation  of  the  Dura  Mater. 

JL  HE  dura  mater  is  sometimes  found  in  a  state  of 
inflammation.  When  this  is  the  case,  many  ex- 
tremely fine  vessels,  filled  with  florid  blood,  are  seen 
in  the  inflamed  portion  of  it,  which  pass  between  the 
dura  mater  and  the  cranium.  These  fine  vessels  are 
seldom  so  crowded  as  in  most  other  parts  of  the  bo- 
dy when  inflamed,  which  arises  from  the  nature  of 
the  membrane  itself.  In  its  natural  state  there  are 
few  blood  vessels  ramifying  through  it  ;  and  there- 
fore, when  it  is  inflamed,  it  does  not  appear  so  much 
crowded  with  vessels  as  other  parts  do  which  are 
naturally  more  vascular.  Still,  however,  a  person 
well  acquainted  with  the  natural  appearance  of  the. 
dura  mater  would  be  as  much  struck  with  the  dif- 
ference of  its  appearance  when  inflamed,  as  he  would 
be  with  that  of  any  other  part  of  the  body. 

The  dura  mater  during  a  state  of  inflammation 
sometimes  forms  a  layer  of  coagulable  lymph,  which 
adheres  upon  its  inner  surface  like  an  adventitious 
membrane  ;  but  this  is  very  uncommon. 

When  the  dura  mater  is  inflamed,  adhesions  are 
sometimes  formed  between  it  and  the  other  mem- 
branes of  the  brain,  so  that  for  a  considerable  extent 
they  adhere  together  ;  but  this  appearance  of  disease 
is  also  very  rare.  The  reason  why  diseased  adhe- 
sions between  the  membranes  of  the  brain  are  rare, 
depends,   probably,    upon  coagulable    lymph  bein^ 

H  h 


£     250     ] 

seldom  thrown  out  upon  their  surface  when  they  arc 
inflamed.  This  may  be  considered  as  a  kind  of  pe- 
culiarity belonging-  to  the  membranes  of  the  brain  r 
for  they  bear  some  analogy  to  the  membranes  which 
line  the  circumscribed  cavities  of  the  body,  and  these 
last  most  commonly  thrown  out  coagulable  lymph 
upon  their  surface  during  inflammation. 

It  is  not  unusual  when  the  dura  mater  has  been  in- 
flamed, especially  in  consequence  of  some  external 
violence,  for  suppuration  to  take  place,  and  pus  to  be 
found  covering  a  portion  of  the  membrane. 

The  dura  mater  is  likewise  sometimes  eroded  by 
ulceration,  but  this  is  by  no  means  frequent :  it  is 
more  common,  in  violent  injuries  of  the  head,  for  a 
portion  of  it  to  become  mortified. 

Scrofulous  Tumours  connected  with  the  Dura  Mater. 

Scrofulous  tumours  are  sometimes  formed  which 
are  connected  with  the  dura  mater,  but  this  happens 
very  rarely.  These  resemble  precisely  the  structure 
of  a  scrofulous  absorbent  gland,  and  occasionally  there 
is  found  in  them  a  curdly  pus. 

•  Spongy  Tumours  growing  from  the  Dura  Mater. 

Spongy  tumours  also  grow  from  the  dura  mater, 
but  they  are  very  uncommon.  Such  tumours,  as  far 
as  I  have  had  an  opportunity  of  examining  them,  are 
pulpy  to  the  touch,  and  of  a  distinct,  fibrous  structure. 

Bony  Matter  formed  in  the  Dura  Mater. 

One  of  the  most  common  diseased  appearances  of 
the  dura  mater,  is  the  formation  of  bony  laminae  in 
some  part  of  it.  These  are  usually  very  small,  being 
not  larger  than  the  nail  of  a  finger,  but  they  are  also 
occasionally  ofa  much  larger  size.  They  are  thin, 
and  frequently  very  irregular  in  their  edge.  They 
are  not  to  be  found  indifferently  in  every  part  of  the 
dura  mater,  but  are  almost  always  adhering  at  the  su- 


[     251     ] 

periour  longitudinal  sinus,  or  its  falciform  process.  In 
some  of  them  the  proportion  of  the  earth  to  the  animal 
part  is  larger  than  in  common  bone. 

There  is  often  one  of  these  ossifications  only  ;  but 
sometim  s  there  are  more  of  them.  The  falciform 
process  has  been  said  to  be  occasionally  found  almost 
entirely  converted  into  bone  ;  but  this  last  appearance 
is  \  cry  rare. 

Very  strong  Adhesions  of  the  Dura  Mater  to  the 
Cranium* 

There  is  at  all  times  a  strong  adhesion  between  the 
dura  mater  and  the  inside  of  the  cranium.  This  ad- 
hesion is  principally  formed  by  small  blood  vessels 
>vhich  pass  from  the  one  to  the  other,  and  likewise  by 
a  close  application  of  the  fibrous  structure  of  the  mem- 
brane to  the  bone.  In  a  natural  state,  however,  the 
dura  mater  can  be  perfectly  separated  from  the  crani- 
um ;  yet  it  sometimes  happens  that  the  adhesion  is 
so  strong,  as  to  render  it  impossible  to  separate  the 
two  completely.  The  dura  mater  in  such  an  attempt 
is  torn  in  different  parts  into  two  lamina:,  one  of  which 
adheres  to  the  bone,  and  the  other  lies  upon  the  pia 
mater.  Whether  this  preternatural  strength  of  adhe- 
sion arises  from  a  previous  state  of  inflammation  in  the 
dura  mater,  or  from  some  other  cause  I  cannot  de- 
termine ;  but  it  is  not  at  all  an  uncommon  appearance. 

Diseased  appearances  of  the  Tunica  A.tclmoidcs. 

Diseased  appearances  of  structure  are  very  rare  in 
the  tunica  arachnoides,  and  have  almost  been  entirely 
overlooked  by  writers.  The  only  diseased  appear- 
ance of  this  coat,  which  I  have  observed,  is  that  of  its 
becoming  a  good  deal  thicker  than  it  is  naturally,  so 
as  to  be  a  tolerably  firm  membrane.  In  this,  as  well 
as  in  its  natural  state,  no  blood  vessels  are  to  be  seen 
ramifying  upon  it ;  or  at  least  they  are  extremely  i\-\\\ 
It  is  also  separated  at  some  distance  from  the  pia 
mater,  by  a  serous  fluid  being  interposed  between 
the  one  and  the  other. 


[     252     3 

Diseased  Appearances  of  the  Pia  Mater. — Veins  of  the 
Pia  Mater  turgid  with  Blood. 

The  most  common  diseased  appearance  of  the  pia 
mattr  is  that  of  its  veins  being  turgid  with  blood. 
This  depends  upon  some  impediment  to  the  free  re- 
turn of  the  blood  from  the  head  towards  the  heart, 
which  may  arise  from  a  variety  of  causes,  and  is  very 
different  from  an  inflamed  state  of  the  pia  mater.  The 
smaller  branches  of  its  arteries,  filled  with  a  florid 
blood,  are  not  more  numerous  in  this  state  than  is 
natural,  but  its  veins  are  much  more  distended  with 
a  dark  blood. 

The  Pia  Mater  inflamed. 

When  the  pia  mater  is  inflamed,  it  is  upOn  the 
whole  more  difficult  to  distinguish  this  from  its  natur- 
al appearance  than  any  other  part  of  the  body  in  the 
same  condition.  This  depends  upon  the  great  num- 
ber of  very  small  vessels  which  naturally  ramify  upon 
it.  In  inflammation  of  the  pia  mater,  these  small  ves- 
sels are  much  .more  numerous  than  in  its  natural 
state,  are  filled  with  a  florid  blood,  and  form  by  their 
anastomosis  a  beautiful  net- work.  It  does  not  fre- 
quently occur,  when  the  pia  mater  is  inflamed,  that 
it  becomes  so  uniformly  red  as  to  shew  no  interstices 
between  its  vessels,  a  circumstance  which  happens  in 
tilt-  inflammation  of  some  other  parts.  The  processes 
arising  from  the  under  surface  of  the  pia  mater  are 
more  crowded  with  vessels  than  usual,  and  there  is  a 
stronger  adhesion  between  them  and  the  substance  of 
the  brain. 

It  very  rarely  happens  that  any  layer  of  coagulable 
lymph  is  formed  in  the  inflammation  of  the  pia  mater 
which  is  so  very  common  in  inflammation  of  the  pleura 
and  the  peritonaeum.  When  the  pia  mater  is  inflam- 
ed to  a  high  degree,  pus  is  formed :  I  have  seen  it 
effused  over  the  whole  upper  surface  of  the  brain,  in 
Consequence  of  an  inflammation  of  the  pia  mater. 


C   2^    J 

Close  adhesions,  for  some  considerable  extent  of 
Surface,  have  been  seen  between  the  pia  and  dura 
mater,  which  are  probably  the  consequence  of  inflam- 
mation ;  but  these  are  very  rare,  and  have  not  fallen 
under  my  own  observation. 

Scrofulous  Tumours  adhering  to  t/w  Pia  Mater. 

I  have  seen  a  number  of  scrofulous  tumours  adher- 
ing to  the  inside  of  the  pia  mater.  They  exhibit  the 
true  scrofulous  structure,  which  has  been  often  ex- 
plained, and  are  very  uncommon. 

Air  in  the  Vessels  of  the  Pia  Mater. 

It  is  not  unusual  to  find  some  of  the  vessels  of  the 
pia  mater  filled  with  air.  This  may  be  generated  by 
putrefaction,  but  it  is  also  sometimes  seen  when  no 
process  of  this  kind  appears  to  have  taken  place.  Un- 
der such  circumstances',  it  is  probable  that  air  is  ex- 
tricated by  some  new  arrangement  in  the  constituent 
parts  of  the  blood. 

Hydatids. 

Little  cysts*  containing  water  (which  are  generally 
called  hydatids,)  have  been  seen  adhering  to  the  pia 
mater;  but  this  is  a  very  rate  appearance  of  disease. 

A  Part  of  the  Pia  Mater  bony. 

Tt  occasionally  happens,  although  I  believe  very 
seldom,  that  a  portion  of  the  pia  mater  is  converted 
into  bone.  It  has  not  occurred  to  me  to  observe  such 
a  change  of  structure  in  this  membrane,  but  Dr. 
Soemmering  mentions  that  a  specimen  of  this  disease 
is  preserved  in  his  collection. 

♦  Vid.  Licuuud,  Tom.  II    p.  115. 


.     C    254    ] 

Diseased  Appearances  in  the  Substance  of  the  Brain. — 
Inflammation. 

The  substance  of  the  brain,  under  which  I  include 
both  the  cerebrum  and  cerebellum,  is  liable  to  inflam- 
mation, although  it  is  not  common,  when  no  external 
injury  has  been  applied  to  the  head.  When  inflam- 
mation takes  place,  it  is  rarely  extended  over  any 
large  portion  of  the  brain,  but  is  rather  confined  to 
one  or  more  distinct  parts  of  it.  In  this  state  of  dis- 
ease the  inflamed  portion  becomes  of  a  red  colour, 
although  this  is  seldom  very  intense.  When  cut  into* 
the  colour  is  found  to  arise  from  a  great  many  small 
vessels,  which  are  filled  with  blood.  If  the  inflamed 
portion  be  upon  the  surface  of  the  brain,  the  mem- 
branes in  the  neighbourhood  are  also  commonly  in- 
flamed. The  part  which  is  inflamed  has  no  peculiar 
hardness,  but  yields  nearly  the  same  sensation  to  the 
touch,  as  it  would  do  in  a  healthy  state. 

Abscesses. 

Inflammation  of  the  brain  frequently  advances  to 
suppuration,  and  abscesses  are  formed  in  it.  When 
these  are  of  a  large  size,  the  weight  of  the  pus  breaks 
down  the  structure  of  the  neighbouring  parts,  and 
they  look  simply  as  if  they  had  been  destroyed,  or 
very  much  injured  by  the  pressure.  When  the  ab- 
scesses are  small,  there  is  an  ulcerated  appearance  of 
the  cavity  in  which  the  pus  is  contained. 

Gangrene. 

Portions  of  the  brain  occasionally  become  gangren- 
ous, especially  after  violent  injuries  of  the  head  ;  but 
I  believe  this  appearance  of  disease  is  extremely  rare, 
where  an  inflammation  of  the  brain  has  taken 
place  from  any  other  cause.  I  have  met,  however, 
with  one.  instance  of  this  ;  a  portion  of  the  brain  at 
the  inflamed  part  was  of  a  very  dark  brown  colour, 
and  as  soft  as  the  most  rotten  pear. 


C     255     ] 

The  Brain  very  soft. 

It  is  extremely  common,  when  the  brain  is  exam- 
ined  in  a  person  who  has  been  dead  for  several  days, 
to  find  such  a  softness  of  its  substance,  that  it  can 
hardly  admit  of  being  cut  so  as  to  leave  a  smooth  sur- 
face, and  the  smallest  pressure  of  the  lingers  breaks 
it  down  into  a  pultaceous  mass.  The  brain,  how- 
ever, will  sometimes  retain,  for  several  days,  the  firm- 
ness and  resistance  which  it  had  during  life  ;  yet  this 
is  by  no  means  common.  Neither  of  these  appear- 
ances is  to  be  considered  as  produced  by  disease. 

Sometimes,  however,  a  part  of  the  medullary  sub- 
stance of  the  brain  becomes  morbidly  soft,  and  loses 
its  natural  texture,  acquiring  nearly  the  consistence 
of  a  custard.  Dr.  John  Hunter,  physician  to  the 
army,  has  observed  this  in  the  medulla  of  the  hemis- 
pheres of  the  brain,  near  the  lateral  ventricles.  He 
has  met  with  this  appearance  in  cases  of  fatuity,  where 
the  persons  were  advanced  in  life,  and  also  combined 
with  effusions  of  blood  in  apoplexy. 


The  Brain  very  Jinn. 

The  brain  is  sometimes  found  to  be  considerably 
firmer  than  in  its  healthy  state,  to  be  tougher,  and  to 
have  a  greater  degree  of  elasticity  than  usual ;  it  will 
bear  to  be  pulled  out  with  some  force,  and  will  readily 
re- act  so  as  to  restore  itself,  or  when  pressed  will  recov- 
er itSjIformer  shape  Under  such  circumstances  the  ven-. 
tricles  are  sometimes  found  to  be  enlarged  in  size, 
and  full  of  water.  The  brain  has  oven  been  said  to 
become  so  hard  and  dry  as  to  be  friable  between  the 
fingers  ;  and  the  medullary  substance,  in  these  cases, 
is  represented  as  being  much  lighter  than  in  a  natural, 
state.  It  is  probable,  however,  that  these  accounts 
are  a  good  deal  exaggerated.  It  has  been  remarked 
that  in  such  cases  the  cerebtllvm  is  very  often  unaf- 
fected. 


[     256     ] 
A  ivhite  firm  Substance  formed  in  the  Brum. 

It  is  not  very  unusual  to  see  a  white  substance 
formed  in  tht  brain  of  an  uniform  smooth  texture, 
and  possessing  a  considerable  degree  of  hardness. 
The  brain  adheres  to  this  substance,  and  round  its 
edge  appears  often  mor  vascular  than  usual.  The 
substance  is  scrofulous  in  its  nature,  for  I  have  had 
an  opportunity  of  seeing  it  converted  into  a  scrofulous 
pus.  There  are  frequently  more  than  one  of  these 
substances  formed  in  the  brain  at  a  time. 

It  is  also  not  unusual  to  find  rounded  masses  of  the 
same  sort  of  substance,  lying  as  it  were  imbedded  in 
the  brain,  or  in  its  interstices ;  some  of  these  I  have 
seen  as  large  as  a  walnut.  When  such  tumours  arc 
formed,  it  happens  frequently  that  there  is  an  increas- 
ed quantity  of  water  in  the  lrteral  ventricles  of  the 
brain. 

Encysted  Tumours  and  Hydatids. 

Encysted  tumours  containing  a  serous  fluid*  have 
sometimes  been  found  in  the  substance  of  the  brain  ; 
but  they  have  never  come  under  my  own  observation, 
and  are  very  uncommon. 

In  one  instance  I  have  known  hydatids  to  be  accu- 
mulated in  the  lateral  ventricles  of  the  brain,  but  this 
is  still  a  more  uncommon  appearance  of  disease  than 
the  other.     They  seemed  to  be  of  the  same  nature- 
with  hydatids  of  the  liver.J 

Bony  Tumours  pressing  upon  the  Brain. 

Bony  tumours  are  sometimes  formed  in  the  crani- 
um, which  press  upon  a  part  of  the  brain.  They 
most  commonly  consist  of  an  irregular  mass,  which 
is  formed  of  bony  processes,  with  a  fleshy   substance 

•  Vid  Lieutaud,  Ton)-  II.  p.  194,  195. 

\  This  case  was  communicated  to   me   by   Mr-  Burnall,   who  attended  »i><» 
patient,  and  examined  the  appearances  after  death. 


C     257     ] 

iilling  up  the  interstices  between  them.  Of  this  sort 
of  tumour  there  are  several  examples  in  Dr.  Hunter'* 
collection. 


It  has  sometimes  happened,  but  very  rarely,  tha£ 
all  the  bones  of  the  cranium  have  become  extremely 
thickened,  and  have  encroached,  by  their  growth,  up- 
on the  cavity  which  contains  the  brain.  Of  this  there 
is  a  remarkable  specimen  in  Mr.  Hunter's  collection, 
where  the  bones  of  the  cranium  arc  at  least  three 
times  as  thick  as  in  the  natural  state.  They  are  also, 
in  the  case  to  which  I  allude,  much  more  spongy  than 
usual  in  their  texture. 


A  nodule  of  a  substance  having  the  appearance  of 
ivory,  has  also  been  known  to  be  formed  in  the  bones 
of  the  cranium,  and  to  protrude  considerably  into  its. 
cavity.  This  too  occurs  very  rarely,  but  a  specimen 
of  it  is  preserved  in  Mr.  Hunter's  collection.  What- 
ever may  be  the  variety  in  the  morbid  processes  which 
produce  these  changes  of  structure  in  the  bones  of 
the  cranium,  their  effects  upon  the  functions  of  the 
brain  must  be  nearly  the  same,  as  they  form  a  perma- 
nent cause  of  compression. 

Bony  Ridges  irritating  the  Brain. 

Upon  the  inner  surface  of  the  basis  of  the  cranium, 
there  is  always  some  irregularity.  This  consists  in- 
numerous  ridges  and  small  eminenries  with  depressed 
surfaces  interposed  between  them.  It  happens  occa- 
sionally that  there  is  a  morbid  growth  of  these  emi- 
nences and  ridges,  forming  sharp  spicula  and  sharp 
edges  of  bone.  These  run  into  the  brain,  and  irritate 
very  violently  the  nervous  system. 

I  i 


E     258     ] 

Hydrocephalus, 

One  of  the  most  common  appearances  of  disease 
in  the  brain,  is  the  accumulation  of  water  in  its  ven- 
tricles 5*  this  generally  takes  place  when  a  child  is 
very  young,  and  even  sometimes  before  birth.  The 
water  is  accumulated  m  greater  or  less  quantity  in 
different  cases.  It  sometimes  amounts  only  to  a  few 
ounces,  and  occasionally  to  many  pints.  When  the 
quantity  of  water  is  very  considerable,  the  fornix  is 
raised  at  its  anterior  extremity  in  consequence  of  its 
accumulation,  and  an  immediate  opening  of  commu- 
nication is  thereby  formed  between  the  lateral  ventri- 
cles.!    From  this  cause  too  a  part  of  the  water  passes 


*  Mr.  Home  has  known  an  instance  where  water  was  accumu- 
lated in  large  quantity  in  the  third  ventricle,  and  had  forced  its 
way  between  the  fine  laminae  of  the  medullary  substance  which 
compose  the  septum  lucidum,  without  escaping  into  either  of  the 
lateral  ventricles.  This  may  be  said  to  be  a  new  situation  of  hy- 
drocephalus, and  is  of  very  lare  occurrence. 

%  A  distinguished  author  has,  in  a  late  publication,  insisted  very 
strongly  upon  the  existence  of  an  immediate  communication  be- 
tween the  two  lateral  ventricles  of  the  brain,  and  has  expressed 
great  surprise  that  it  has  been  denied  by  several  teachers  of  anat- 
omy in  London.  Without  entering  into  any  dispute  about  this 
matter,  which  in  itself  is  of  no  great  importance^  I  shall  briefly 
mention  what  appears  to  me  to  be  the  real  state  of  the  circum- 
stances. The  fornix  at  its  anterior  extremity  lies  loose  upon  a 
part  of  thethalami  nervorum  opticorum,  and  there  is  a  small  chink 
on  each  side  of  the  fornix  leading  obliquely  downwards  from  the 
lateral  ventricles  to  the  anterior  extremity  of  the  third  ventricle. 
While  the  fornix  is  allowed  to  remain  in  its  natural  situation, 
there  seems  to  me  to  be  no  immediate  communication  between 
the  Literal  ventricles.  But  when  the  fornix  is  t levated  (which 
may  be  very  easily  done)  then  the  lateral  ventricles  communicate 
directly  with  each  other  ;  and  the  communication  is  more  or  less 
according  to  the  degree  of  the  elevation.  It  may  be  said,  that  the 
lateral  ventricles  still  communicate  together  by  means  of  the  third 
ventricle.  This,  however,  is  riot  properly  an  immediate  com* 
muiiicalion  between  the  two  lateral  ventricles,  unless  any  two  cav- 
ities which  communicate  with  a  third,  may  be  properly  said  to 
communicate  directly  or  immediately  Avith  each  other. 


[     259     ] 

very  readily  into  the  third  ventricle,  and  from  thence 
into  the  fourth.  The  water  is  of  a  purer  colour,  and 
more  limpid,  than  what  is  found  in  dropsy  of  the 
thorax  or  abdomen.  It  appears,  however,  to  be  gener- 
ally of  the  same  nature  with  the  water  that  is  accumu- 
lated in  both  of  those  large  cavities.  In  some  trials 
which  I  have  made,  it  partly  coagulated  upon  the 
application  of  the  common  acids,  exactly  like  the 
water  in  hydrothorax  and  ascites,  or  like  the  serum 
of  the  blood.  But  there  is  much  variety  in  the  quan- 
tity of  the  coagulable  matter.  In  some  instances  the 
water  in  hydrocephalus  contains  a  very  small  pro- 
portion of  coagulable  matter,  and  in  others  it  is  almost 
entirely  free  from  it. 

When  water  is  accumulated  in  the  ventricles  to  a 
very  large  quantity,  the  substance  of  the  brain, 
especially  upon  the  sides  and  at  the  upper  surface, 
appears  almost  to  be  a  sort  of  pulpy  bag,  containing  a 
fluid.  The  scull  too  upon  such  occasions  is  very 
much  enlarged  in  size,  and  altered  in  its  shape.  The 
cranium  is  exceedingly  large  in  proportion  to  the 
size  of  the  face.  The  projections  are  very  consid- 
able  at  the  centres  of  ossification,  from  whence  the 
frontal,  parietal,  and  occipital  bones  were  originally 
formed,  and  the  membranous  divisions  between  these 
several  bones  are  very  wide.  When  the  scalp  is  re- 
moved, so  as  to  give  an  oportunity  of  looking  imme- 
diately upon  the  cranium,  the  bones  are  found  to  be 
very  thin,  often  not  thicker  than  a  shilling,  and 
there  are  frequently  broad  spots  of  membrane  in  the 
bene.  The  reason  of  this  last  appearance  is,  that 
ossification  takes  place  in  many  points  of  the  mem- 
brane in  such  cases  in  order  to  make  a  quicker  prog- 
ress, but  the  water  accumulates  too  rapidly  for  it, 
so  that  spots  of  membrane  are  left  not  converted  into 
bone.  When  such  appearances  take  place  in  hydroce- 
phalus, the  disease  has  been  of  long  continuance,  oc- 
casionally for  some  years. 


C     260     ] 

Water  upon  the  Surface  of  the  Brain>  and  between  its 
Membranes. 


Water  is  also  sometimes  formed  under  the  pia 
mater,  and  upon  the  surface  of  the  brain,  but  very 
rarely  in  any  considerable  quantity.  There  is,  gen- 
erally, at  the  same  time,  a  greater  quantity  than  natu- 
ral in  the  ventricles. 

Water  is  likewise  found  in  small  quantity  between 
the  dura  and  pia  mater. 

It  is  related  by  authors,  that  water  has  been  form- 
ed occasionally  between  the  dura  mater  and  the  crani- 
um.* From  the  nature  of  the  adhesion  between  the 
cranium  and  this  membrane  one  would  not  easily  be 
led  to  suspect  an  accumulation  of  water  between 
them,  and  such  cases  are  at  least  to  be  considered  as 
very  uncommon. 

Blood  effused  or  extravasated. 

Blood  is  frequently  found  effused  within  the  cavity 
of  the  cranium  in  various  situations.  It  may  either 
be  poured  out  by  the  rupture  of  some  vessel  in  the 
substance  of  the  brain  itself,  or  into  some  of  the  ven- 
tricles. It  is  frequently  effused  upon  the  surface  of 
the  brain,  or  upon  some  of  its  membranes.  This  is 
most  apt  to  happen  where  the  effusion  is  in  conse- 
quence of  external  violence. 

The  quantity  of  blood  which  is  effused  from  the 
rupture  of  vessels  in  the  brain  is  frequently  very 
considerable.  It  is  commonly  found  in  a  coagulated 
state,  and  the  texture  of  the  brain  in  the  neighborhood 
is  often  very  much  hurt  from  the  pressure.  Blood  is 
is  not  equally  liable  to  be  effused  into  every  part  of 

•  Vid.  Lieutaud,  Tom-  II.  p.  229,  2S0. 


C     261     ] 

the  substance  of  the  brain.  Where  an  effusion  has 
taken  place  without  external  injury,  it  is  almost  con- 
stantly found  in  the  medullary  part  of  one  of  the  hem- 
ispheres, and  often  near  the  lateral  ventricles,  so  that 
a  quantity  of  blood  has  at  the  same  time  escaped  into 
one  or  both  of  these  cavities.  It  sometimes  happens 
that  the  brain  is  very  soft  in  its  consistence  at  the 
place  of  this  effusion,  a  remark  which  has  been  made 
by  Dr   John  Hunter. 

When  blood  is  extravasated  within  the  cavity  of 
the  cranium  from  some  external  injury,  the  vascular 
System  is  usually  sound,  except  for  the  rupture 
which  may  have  happened.  But  when  extravasation 
happens  within  the  cavity  of  the  cranium,  without 
internal  injury,  the  vascular  system  of  the  brain  is 
almost  always  diseased.  It  is  very  common  in  ex- 
amining the  brains  of  persons  who  are  considerably- 
advanced  in  life,  to  find  the  trunks  of  the  internal 
carotid  arteries  upon  the  side  of  the  sella  turcica  very 
much  diseased,  and  this  disease  extends  frequently 
more  or  less  into  the  small  branches.  The  disease 
consists  in  a  bony  or  earthy  matter  being  deposited  in 
the  coats  of  the  arteries,  by  which  they  lose  a  part  of 
their  contractile  and  distensile  powers,  as  well  as  of 
their  tenacity.  The  same  sort  of  diseased  structure 
is  likewise  found  in  the  basilary  artery  and  its  branch- 
es. 

The  vessels  of  the  brain  under  such  circumstances 
of  disease,  are  much  more  liable  to  be  ruptured  than 
in  a  healthy  state.  Whenever  blood  is  accumulated 
in  unusual  quantity,  or  the  circuation  is  going  on  in 
them  with  unusual  vigour,  they  are  liable  to  this  ac- 
cident, and  accordingly  in  either  of  these  states,  ex- 
travasations of  blood  frequently  happen.  Were  the 
internal  carotid  arteries  and  the  basilary  artery  not 
subject  to  the  diseased  alteration  of  structure  which 
we  have  described,  effusions  of  blood  within  the  cavi- 


t     282     ] 

ty  of  the  cranium,  where  there  lias  been  no  previous 
external  injury,  would  probably   be  much  more  rare 


Cavities  in  the  Brain  containing  a  serous  Fluid. 

Cavities  containing  a  serous  fluid  are  sometimes 
observed  in  the  substance  of  the  brain.  They  al- 
most constantly  occur  in  the  medullary  part  of  the 
hemispheres,  and  the  substance  of  the  brain  immedi- 
ately surrounding  these  cavities  is  tough  and  smooth, 
so  as  to  resemble  a  membrane.  They  would  appear 
to  be  the  remains  of  the  cavities  formed  by  extrava- 
sated  blood,  in  cases  of  apoplexy,  where  the  patients 
hive  lived  afterwards  for  some  months  or  years. 
The  extravasated  blood  would  seem  in  such  cases 
to  have, been  dissolved,  and  taken  up  by  absorption  ; 
but  the  injury  is  not  repaired,  and  a  cavity  remains 
afterwards  filled  with  a  serous  fluid.*" 


Aneurysm  of  the  internal  Carotid  Arteries  on  the  Side 
of  the  Sella  Turcica. 


The  internal  carotid  arteries  arc  very  apt,  in  per- 
sons of  an  advanced  age,  to  become  ossified,  and  the 
same  morbid  change  may  be  traced  along  their 
branches.     It  occurs,  however,  very  rarely,  that  they 


*  I  had  an  opportunity  of  observing,  lately,,  a  well  marked  case 
of  this  soi  t,  in  a  person  who  bad  had  several  attacks  of  the  apo- 
plexy, and  at  length  was  cut  off  by  one  of  them.  Dr.  John  Hunt- 
er has  observed  a  good  many  instances  of  it,  and  a  case  occurred 
some  years  ago  to  Mr.  Wilson,  lecturer  on  anatomy,  whose  ac- 
curacy is  well  known,  where  the  cavity  which  remained  was  61  a 
refv  lafee  siz^. 


[     263     ] 

are  distended  at  any  part  into  an  aneurysmal  sack, 
like  the  arteries  in  some  other  parts  of  the  body.  I 
have  been  informed  of  an  instance  of  this  kind,  where 
both  the  internal  carotid  arteries,  on  the  side  of  the 
sella  turcica,  were  distended  into  a  little  aneurysm.* 
One  of  these  aneurysms  was  about  the  size  of  a  cher- 
ry and  the  other  was  somewhat  smaller.  It  is  re- 
markable that  in  the  onlv  two  instances  which  have 
come  to  my  knowledge,  of  aneurysms  being  formed 
in  the  arteries  of  the  head  and  brain,  there  has  been 
an  aneurysm  in  both  arteries  in  the  same  situation, 
and  at  the  same  time.  I  once  met  with  an  aneurysm 
in  each  of  the  carotid  arteries  at  the  origin  of  the  in- 
ternal carotids,  and  in  the  case  just  described,  there 
was  an  aneurysm  in  each  of  the  two  internal  carotid 
arteries  upon  the  side  of  the  sella  turcica. 


Diseased  Appearances  of  the  Plexus  CJioroides. — Lit- 
tle Bags  in  the  Plexus  Choroides. 


The  most  common  diseased  appearance  of  the 
plexus  choroides  is  that  of  little  round  transparent 
bags,  which  adhere  to  it,  and  which  have  commonly 
bcen  called  hydatids.  These  are  generally  about 
the  size  of  a  garden  pea,  but  sometimes,  they  have 
been  seen  as  large  as  a  gooseberry.  From  several  ex- 
aminations which  I  have  made  of  them,  they  would 
seem  to  be  formed  by  a  distension  of  the  vein  which 
runs  along  the  edge  of  the  plexus  choroides;  I  have 
been  able  to  distend  them  fully  with  air,  by  making 
an  opening  into  this  vein,  and  inflating  air  into  it 
through  a  small  blowpipe. 

*  I  owe  my  acquaintance  with  thrs  case  lo  Dr.  Blatie. 


[    264     ] 


Round  Tuinours  adhering  to  the  Plexus    Choroides* 

Tumours  sometimes  adhere  to  the  plexus  cho- 
roides.  They  are  small  in  their  size,  of  a  round 
shape,  and  occur  but  rarely.  They  seem  to  be  the 
same  kind  with  the  round  tumours  which  are  some- 
times found  imbedded  in  the  brain,  and  I  believe 
are  scrofulous. 


Diseased  appearances  of  the  Pineal  Gland. — Earthy 
Matter  in  the  Pineal  Gland. 


A  little  earthy  matter  is  almost  constantly  found  in 
the  pineal  gland.  It  is  sometimes  in  very  small 
quantity,  but  not  unfrequently  the  quantity  is  very 
considerable.  The  particles  of  the  earth  do  not 
adhere  strongly  together,  but  are  easily  separable  by 
pressure  between  the  fingers.  The  existence  of  a 
small  quantity  of  earth  is  so  common  in  the  pineal 
gland,  that  it  cannot  well  be  considered  as  a  disease. 
I  think,  however,  that  in  some  instances  I  have 
found  this  gland  without  any  deposition  of  earthy 
matter. 


Pineal  Gland  said  to  be  scirrhous. 


The  pineal  gland  has  been  mentioned  by  authors, 
as  being  sometimes  scirrhous.  1  have  felt  it  on 
some  occasions  a  little  firmer  than  on  others  ;  but  it 


[     265     ] 

has  never  occurred  to  me  to  observe  that  alteration 
of  structure  in  it,  which  could  be  properly  called 
scirrhous,  and  I  believe  it  to  be  a  very  rare  disease. 


Water  in  the  Pineal  Gland. 

The  pineal  gland  has  been  found  to  be  very  much 
distended  with  a  limpid  water  ;*  but  this  too  is  very 
uncommon. 


Diseased  Appearances  of  the  Pituitary  Gland, 

This  gland  is  very  little  liable  to  be  affected  by 
disease.  It  has  only  occurred  to  me  to  observe  in  it 
one  morbid  change.  It  was,  in  that  case,  enlarged  to 
twice  its  natural  size,  and  was  converted  into  a  sub- 
stance, possessing  an  obscurely  fibrous  structure. 


Diseased  Appearances  of  the  Nerves. 

It  rarely  happens  that  any  of  the  nerves  within 
the  cavity  of  the  cranium  appear  diseased.  I  have, 
however,  sometimes  seen  a  nerve  a  good  deal  small- 
er in  its  size  than  it  ought  to  be,  softer  in  its  texture, 
and  of  a  less  opaque  colour  ;  this  I  recollect  to  have 

■  Ykl.  Morgagni,  Epist.  LXII.  Art.   15. 

K  k 


[     266     J 

been  particularly  the  case  with  one  of  the  optic  nerves 
in  a  person  who  was  blind  of  one  eye.* 

The  nerves  vary  a  good  deal  in  their  size  indiffe- 
rent persons,  as  a  part  of  their  original  formation, 
without  there  being  any  disease  whatever. 


Mal-formations  of  the  Brain, 


These  are  the  principal  diseased  changes  which 
take  place  in  the  brain  and  its  appendages.  I  have 
just  to  add,  that  the  brain  is  subject  a  great  variety 
from  original  monstrous  formation.  A  great  part  of 
what  is  usually  called  the  cerebrum  is  sometimes 
wanting,  while  the  cerebellum,  and  the  medulla  spi- 
nalis are  entire  ;  sometimes  there  is  hardly  any  vestige 
of  either  the  cerebrum  or  cerebellum,  and  the  medulla 
spinalis  is  very  much  diminished  in  size  ;  at  other 
times  there  is  a  total  want  of  the  brain,  and  there  is  no 
appearance  of  the  medulla  spinales.  In  this  case  one 
should  expect  a  want  of  nerves  through  the  whole 
body.  It  is,  however,  not  so  ;  nerves  are  found 
distributed  in  the  common  way,  through  the  limbs, 
and  the  dorsal  nerves  can  be  seen  arising  from  a 
membrane  somewhat  resembling  the  dura  mater  in 


*  I  have  seen  an  instance  of  a  considerable  tumour  being  form- 
ed in  a  nerve.  The  tumour  was  very  solid  in  its  texture,  of  a 
yellowish  white  colour,  and  larger  in  its  size  than  a  goose's  egg. 
The  nerve  seemed  to  be  in  some  measure  lost  in  the  tumour,  and 
in  one  part  of  it  a  fibrous  structure  could  be  observed  pretty  dia^ 
tinctly,  similar  to  that  of  a  nerve.  This  swelling  occurred  in  one 
of  the  auxiliary  nerves,  and  was  extirpated  by  Mr.  Heme,  at  St». 
G<eorge's  Hospital. 


[     267     ] 

the  canal  behind  the  vertebra?.  When  there  is  a 
total  \vtint  of  brain,  it  sometimes  happens  that  there 
is  a  medulla  spinalis,  which,  however,  is  of  a  very- 
small  size.  In  cases  of  deficiency  in  the  brain,  the 
cranium  is  nearly  upon  a  level  with  the  two  eyes,  and 
there  is  often  upon  the  scalp  a  soft,  spongy  excres- 
cence. This  is  generally  divided  into  distinct  pro- 
tuberant masses,  and  is  covered  with  a  fine  skin, 
capable  of  being  rendered  very  vascular  by  injection. 
When  cut  into,  the  spongy  excrescence  consists  of 
pretty  large  cells,  which  are  filled  with  a  sort  of  gru- 
mous  matter, 

There  is  also  frequently,  instead  of  this  excrescence, 
a  bag  growing  from  the  skin  of  the  scalp,  and  passing 
downwards  so  as  to  cover  more  or  less  of  the  back 
of  the  trunk.  This  bag  sometimes  consists  of  a  fine 
membrane,  with  little  strength  ;  and  sometimes  it  is 
rather  thick,  with  considerable  firmness.  It  some- 
times communicates  with  the  cavity  of  the  cranium 
by  a  considerable  opening  ;  and  sometimes  the  com- 
munication is  very  small.  It  is  filled  with  an  aque- 
ous fluid,  and  in  some  instances  there  is  also  iu  it  a 
portion  of  the  brain* 


SYMPTOMS. 


Inflammation  of  the  dura  mater  is  not  distinguished 
by  any  peculiar  symptoms.  The  symptoms  which 
belong  to  it,  ?re  the  same  with  those  which  attend 
inflammation  of  the  other  membranes,  and  even  difFes 


[     268     ] 

but  little  from  the  symptoms  which  take  place  in  in- 
flammation of  the  brain  itself.  The  symptoms  are, 
pain  in  the  head,  delirium,  symptomatic  fever,  and 
sometimes  convulsive  motions. 


When  tumours  have  been  found  adhering  to  the 
dura  mater,  or  the  other  membranes  of  the  brain,  a 
long  continued  pain  in  the  head  has  commonly  been 
remarked,  sometimes  delirium,  sometimes  convul- 
sions, and  sometimes  it  has  been  said,  the  ordinary 
symptoms  of  apoplexy. 


Where  bony  matter  has  been  formed  in  the  dura 
mater,  with  sharp  processes  growing  from  it,  convul- 
sive motions  have  very  commonly  occurred  in  various 
parts  of  the  body,  often  a  continued  pain  in  the  head, 
and  sometimes  delirium* 


Incases  where  the  veins  of  the  pia  mater  have 
been  found  turgid  with  blood,  stupor  has  very  fre- 
quently occurred,  sometimes  delirium,  and  some- 
times, it  has  been  said  even  apoplexy  in  its  perfect 
form. 


The  symptoms  of  inflammation  in  the  pia  mater, 
are  the  samq  with  those  which  attend  inflammation  of 
the  dura  mater,  and  they  have  been  already  noticed. 


f    269     ] 


In  inflammation  of  the  substance  of  the  brain,  there 
is  pain  in  the  head,  delirium,  symptomatic  fever,  and 
sometimes  coma. 


Where  an  abscess  has  been  formed  in  the  brain, 
pain,  delirium,  and  coma,  have  been  remarked,  some- 
times a  paralysis  of  a  part  of  the  body,  and  sometimes 
convulsions.  The  last  symptom  has  been  observed 
most  frequently  to  occur  when  the  abscess  has  been 
formed  in  the  tuberculum  annulare  or  in  the  medulla 
oblongata,  or  in  the  neighbourhood  of  these  structures 
so  that  the  pus  could  affect  them  by  its  pressure. 


The  brain  has  sometimes  been  found  more  firm 
\nd  elastic  than  is  natural  in  cases  of  mania.  I  have 
been  informed,  however,  lately,  from  the  best  au- 
thority, that  this  state  of  brain  is  not  common  in 
maniacs  ;  and  that  in  them  it  is  generally  not  more 
firm,  nor  more  elastic,  than  in  people  whose  minds 
have  always  been  sound. 


The  symptoms  which  have  been  observed  to  at- 
tend  the  formation  of  solid,  or  encysted  tumours  in 
the  brain,  are  a  permanent  pain  in  the  head,  which 
is  occasionally  very  violent,  sometimes  delirium, 
sometimes  convulsions,  and  sometimes,  it  has  been 
said,  the  common  symptoms  of  apoplexy.  It  is 
worthy  of  remark  here,  that  when  tumours  of  any 
kind  press  upon  the  thalami  nervorum  opticorum, 
or  the  optic  nerves  themselves,   within  the  cranium, 


C   2-0   ] 

Vision  generally  becomes  impaired  in  various  ways  ;* 
and  that  when  tumours  press  upon  the  tuberculum 
annulare,  or  the  medulla  oblongata,  convulsions  are 
very  apt  to  occur. 

In  the  case  where  hydatids  were  accumulated  in  the 
lateral  ventricles,  the  person  had  been  subject  for  a  long 
time  to  pain  in  his  bead,  which  was  often  violent,  8c  to- 
wards the  close  of  the  disease,  had  several  convulsion- 
fits,  in  one  of  which  he  expired.  Neither  his  sight 
nor  hearing  were  impaired. 


The  symptoms  of  hydrocephalus,  are  a  pain  in  the 
head,  stupor,  convulsive  motions,  picking  of  the  nose, 
grinding  of  the  teeth  during  sleep,  occasional  flushings 
of  the  face,  and  towards  the  latter  end  of  the  disease,  a 
dilatation  of  the  pupils  and  squinting.  The  stomach  is 
commonly  affected  with  sickness,  and  the  bowels  are 
with  difficulty  acted  upon  by  purgative  medicines.  In 
the  beginning  of  this  disease,  the  pulse  is  frequent  but 
regular  ;  when  the  disease  has  made  a  further  prog- 
ress, it  is  slow  and  irregular  ;  and  towards  the  latter 
end  of  the  disease,  it  becomes  again  more  regular  and 
frequent.  When  the  progress  of  the  disease  has  been 
very  gradual,  and  the  patient  has  continued  to  live  for 
some  months,  or  even  years,  the  functions  of  the  brain 
have  been  found  in  many  instances,  to  be  less  impaired 
than  might  have  been  expected,  till  near  its  close. 


Where  blood  has  been  effused  upon  any  of  the 
membranes  of  the  brain,  the  patient  is  more  or  less  in 
a  comatose   state,    according  to  the  degree   of  the 

*  I  have  known  one  case  in  which  the  optic  nerves  at  their  junc- 
tion were  pressed  by  a  tumour  as  large  as  a  gooseberry,  and  yet 
the  pupils  were  not  dilated,  nor  the  eyesight  impaired,  till  within 
a  day  or  two  of  the  person's  death.  There  was  onty  a  very  vio- 
lent pain  in  the  fore  part  of  the  head. 


C     271     ] 

effusion,  or  the  different  susceptibility  of  tlic  brain  m 
different  individuals  to  be  affected  by  pressure.  In- 
numerable instances  shew,  that  the  brain  will  have 
its  functions  impaired  in  very  different  degrees, 
from  the  same  apparent  degree  of  injury. 

When  blood  is  effused  into  the  substance  of  the 
brain,  apoplexy  is  produced,  which  is  attended  with 
the  following  symptoms,  viz.  coma  ;  often  stertor- 
ous breathing  ;  a  paralysis,  commonly  of  one  half  of 
the  body  ;  and  often  convulsive  motions.  The  pulse 
is  slow,  full,  and  generally  very  strong.  When  the 
patient  is  not  cut  off  at  once,  but  lives  for  some  time 
after  the  attack,  the  hemiphlegia,  which  is  almost 
«onstantly  an  effect  of  this  disease,  is  generally  upon 
the  opposite  side  of  the  body  from  that  of  the  brain, 
in  which  the  effusion  of  blood  has  taken  place.  This 
would  seem  to  shew,  that  the  right  side  of  the  body 
derives  its  nervous  influence  from  the  left  side  of  the 
brain,  and  the  left  side  of  the  body  its  nervous  influ- 
ence from  the  right  side  of  the  brain.  In  a  few  instan- 
ces, however,  the  hemiphlegia  has  occurred  on  thr 
same  side  of  the  body  with  the  effusion.* 


*  Dr.  John  Hunter  has  made  some  very  accurate  dissections 
relative  to  apoplexy,  and  its  consequences,  which  formed  the  subl- 
ject  of  the  (iulstonian  lectures,  read  by  him,  1796,  before  the 
College  of  Physicians.  By  these  lectures,  I  have  been  enabled 
to  give  a  more  satisfactory  account  of  the  appearances  connected 
frith  this  disease,  than  I  should  have  been  otherwise. 


w^e-N&S)  USSEBI  STNfc^  . 


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